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OF  THE 

UNIVERSITY  OF  NORTH  CAROLINA 
AT  CHAPEL  HILL 


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•v* 


M  H 


,  /w 


REPORT 


ON  THE 


MEDICAL  TOPOGRAPHY  AND  EPIDEMICS 


OP 


NORTH  CAROLINA. 


BY 

JAMES  H.  DICKSON,  M.  D. 


EXTRACTED  FROM  THE 

TRANSACTIONS  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 


PHILADELPHIA: 

COLLINS,  PRINTED,  705  JAYNE  STREET. 

1860. 


7 


REPORT  ON  THE  MEDICAL  TOPOGRAPHY  AND 
EPIDEMICS  OF  NORTH  CAROLINA. 


MEDICAL  TOPOGRAPHY. 


The  State  of  North  Carolina,  embracing  an  area  of  more  than 
fifty  thousand  square  miles,  extending  from  34°  to  36°  30'  of  north 
latitude  and  from  longitude  1J°  east  to  7°  west  of  Washington, 
and  from  the  Atlantic  Ocean  on  the  east  to  the  Alleghany  Moun¬ 
tains  on  the  west,  would  seem  to  present  a  sufficiently  wide  range 
of  geological,  meteorological,  and  climatic  conditions  to  give  origin 
to  no  inconsiderable  variety  of  diseases. 

If,  however,  any  reliable  results  can  be  deduced  from  the  con¬ 
fessedly  meagre  and  imperfect  reports  which  I  have  been  able  to 
procure  from  different  parts  of  the  State,  there  will  be  found  very 
great  uniformity  in  the  diseases  of  all  parts  of  its  extended  area. 

On  the  eastern  or  Atlantic  border  of  the  State,  there  is  an  ex¬ 
tensive  region  of  low,  swampy,  alluvial  formation,  but  little  elevated 
above  the  level  of  the  ocean,  which,  as  the  country  recedes  from  the 
coast,  merges  into  a  wide,  flat,  sandy  region  of  a  somewhat  higher 
level,  covered  with  extensive  forests  of  pine,  and  gradually  in¬ 
creasing  in  elevation  until  the  head  of  navigation  of  its  principal 
rivers  is  reached,  when  the  face  of  the  country  becomes  rolling 
and  hilly,  and  the  pine  forests  abruptly  disappear ;  being  replaced 
by  a  growth  of  oaks  of  great  variety,  and  of  hickory,  poplar,  syca¬ 
more,  black  walnut,  beech,  maple,  &c. 

The  entire  eastern  section  of  the  State,  from  the  seacoast  to 
the  first  rapids  in  the  principal  rivers,  at  an  average  distance  of 
about  an  hundred  miles  from  the  ocean,  is  without  doubt  a  marine 
formation,  or  sedimentary  deposits  from  water,  and  therefore  wholly 
unlike  those  of  the  middle  and  western  parts,  which  are  the  pro¬ 
duct  of  the  slow  decomposition  of  the  primitive  rocks;  and  occupy 


D  h  V 

\%l»Q 


0 


REPORT  ON 


the  place  upon  the  original  formation,  from  which  they  were  de¬ 
rived. 

The  soil  of  the  eastern  section  has  evidently  been  transported 
from  a  distance.  Its  prevailing  character  is  silicious,  derived  ap¬ 
parently  from  the  granite  which  borders  the  tertiary  formation  on 
the  west.  From  the  same  source  is  probably  also  derived  the 
aluminous  and  feldspathic  portions  of  the  soil,  which  enter  into 
the  composition  of  the  inexhaustibly  rich-  swamp  lands  of  the 
eastern  counties. 

The  hilly  middle  region  of  the  State  has  generally  an  argillaceous 
soil  variously  intermixed  with  silex,  micft,  and  different  mineral 
ingredients.  It  has  had,  and  still  retains,  a  high  character  for  the 
salubrity  of  its  climate  and  the  fertility  of  its  soil.  We  may  regard 
this  section  of  the  State  as  extending  to  the  base  of  the  Blue 
Ridge  Mountains  by  a  gradually  increasing  elevation. 

The  mountainous  portion  of  the  State,  as  indicated  by  recent 
surveys,  embraces  the  highest  elevation  of  any  portion  of  North 
America  east  of  the  Rocky  Mountains. 

The  littoral  margin  of  the  State  of  North  Carolina  is  unique 
and  almost  peculiar  in  one  of  its  geological  features.  At  a  distance 
varying  from  two  to  five  miles  from  the  main  land  a  narrow  strip 
of  sandbank  runs  parallel  with  the  coast  and  nearly  continuous  with 
it,  like  a  giant  breakwater,  thrown  up  apparently  by  the  action  of 
the  waves  of  the  sea ;  these  sandbanks  are  for  the  most  part  bare 
of  vegetation ;  some  portions,  however,  are  covered  with  a  thick 
growth  of  live-oak,  cedar,  and  yopon,  which  latter  shrub  is  regarded 
by  competent  authority  asvidentical  with  the  much  valued  matte  of 
Paraguay.  The  continuity  of  this  strip  of  sandbanks,  is  occasion¬ 
ally  broken  by  narrow  inlets;  and  between  the  banks  and  the  main 
land,  there  intervenes  a  shallow  sound,  which  is  for  the  most  part 
occupied  with  a  rank  growth  of  marsh  grass,  which  is  alternately 
covered  and  left  bare  by  the  rising  and  falling  tides. 

It  thus  presents  precisely  those  conditions  of  insalubrity  which 
Armstrong,  in  his  “Art  of  Health,”  so  graphically  groups  in  the 
couplet  which  follows : — 

“  Not' for  the  wealth  of  all  the  Indies  roll’d 
Fix  near  the  marshy  margin  of  the  main.” 

There  is  doubtless  something  of  truth  as  well  as  poetry  in  the 
lines,  although  we  are  apt  to  suspect  the  writer  to  have  been 
influenced  in  some  degree  by  the  beauty  of  the  alliteration,  when 


THE  EPIDEMICS  OF  NORTH  CAROLINA1  7 

A 

penning  them ;  however  true  they  may  be  in  their  application  to 
many  localities,  our  coast  can  hardly  be  ranked  among  them ;  for 
it  is  favored  with  delightful  breezes  during  the  summer  which 
sweep  away  such  impurities  as  are  supposed  to  be  engendered  by 
the  action  of  the  hot  sun  on  marshy  soils;  at  any  rate,  so  far  from 
being  more  subject  to  the  visitation  of  intermittent  and  remittent 
fevers,  than  the  adjacent  counties,  the  seashore  has  acquired  quite 
a  reputation  for  salubrity,  and  is  a  common  summer  resort  for  many 
of  the  inhabitants  of  the  interior. 

In  the  most  easterly  portion  of  the  State,  the  strip  of  sandbanks 
just  noticed  recedes  considerably  farther  from  the  main  land,  leaving 
an  intervening  space  of  many  miles  in  extent,  which  is  occupied, 
mainly,  by  Pamlico  and  Albemarle  Sounds,  extensive  sheets  of 
water,  into  which  most  of  the  rivers  which  drain  the  middle  and 
eastern  portions  of  the  State,  among  which  may  be  mentioned  the 
Roanoke,  the  Tar,  the  Neuse,  disembogue  by  wide  estuaries. 

The  country  along  the  margin  of  the  sounds  and  the  estuaries  of 
the  rivers,  may  be  generally  characterized  as  swampy ;  elevated 
but  a  little  above  the  level  of  the  ocean,  being  of  the  most  re¬ 
cent  geological  formation,  and  consisting  largely  of  decomposed 
vegetable  matter,  which  confers  upon  it  great  fertility,  and  at  the 
same  time  stamps  it  with  the  character  of  insalubrity. 

A  very  considerable  portion  of  all  the  littoral  counties  of  the 
State,  especially  along  the  margins  of  the  rivers  and  creeks,  is  of 
the  same  swampy  character,  for  the  most  part  fertile,  but  unhealthy. 
'Throughout  the  middle  and  western  divisions  of  the  State,  valua¬ 
ble  minerals  are  found  in  abundance;  among  them,  ores  of  iron, 
copper,  and  gold,  and  in  the  middle  region  of  the  State,  on  the  belt 
of  sandstone,  which  crosses  it,  are  found  bituminous,  semi-bitumi¬ 
nous,  and  anthracite  coals. 

The  mountainous  portion  of  the  State,  embracing  about  one  tenth 
of  its  superficial  area,  is  remarkable  for  its  salubrity  and  its  altitude, 
and  for  a  considerable  extent,  forms  the  dividing  ridge,  from  which, 
on  the  one  side,  the  rivers  flow  into  the  Atlantic  Ocean,  and  on  the 
other,  into  the  Mississippi  River  and  the  Gulf  of  Mexico.  From 
one  point,  indeed,  the  waters  flow  north,  south,  east,  and  west,  into 
Virginia,  South  Carolina,  Tennessee,  and  the  Atlantic ;  a  geographi¬ 
cal  feature  which  is  believed  to  be  peculiar  to  this  State. 

Another  remarkable  peculiarity  of  this  mountain  region  of  the 
State  of  North  Carolina,  is  the  existence  of  a  belt  or  zone,  which  is 
characterized  by  an  entire  exemption  from  frost.  Frost  occurs 


8 


REPORT  ON 


both  above  and  below  this  remarkable  zone,  and  the  strange  spec* 
tacle  is  sometimes  presented  of  vegetation  blighted  by  frost  both  at 
the  base  and  apes  of  the  mountain,  while  the  intermediate  region 
presents  to  the  eye  the  blooming  verdure  of  spring.  Here,  fruit 
falling  from  the  trees,  needs  no  protection  during  the  winter;  here, 
the  vine  flourishes  in  great  perfection,  and  our  sanguine  agricul¬ 
turists  are  anticipating,  for  this  part  of  the  State,  great  success  as  a 
wine  making  region. 

DISEASES, 

The  great  endemic  of  southern  climates,  Bilious  Remittent  Fever, 
claims  the  first  place  in  the  nosography  of  this  State. 

BILIOUS  REMITTENT  FEVER. 

For  many  years,  it  may  be  said  to  have  been  the  reigning  epi¬ 
demic  of  the  entire  eastern  section  of  the  State,  of  such  uniform 
occurence  in  the  summer  and  fall,  and  so  formidable  in  its  character, 
that  few  who  had  the  ability  to  remove  to  more  salubrious  localities, 
were  accustomed  to  remain  during  the  season  of  its  prevalence,  in 
the  low  country. 

This  form  of  fever,  so  unfailing  in  its  periodical  visitations,  often 
beginning  as  early  as  June  and  remaining  until  the  occurrence  of 
frost,  which  generally  takes  place  in  the  latter  part  of  October,  has 
of  late  years,  lost  much  of  its  malignity  in  the  low  country,  but 
seems  to  have  acquired  an  increased  power  of  diffusion,  having 
gradually  encroached  upon  the  middle  region  of  the  State,  and  ex¬ 
tended  itself  almost  to  the  base  of  the  Blue  Ridge  Mountains. 

A  few  years  ago  the  remittent  and  intermittent  forms  of  fever 
were  as  prevalent  in  Salisbury,  Concord,  and  Charlotte,  in  the 
middle  region  of  the  State,  as  in  any  of  the  counties  on  the  sea¬ 
board. 

I  am  informed  by  physicians  resident  in  the  mountains,  that 
these  forms  of  fever  are  never  known  to  originate  there,  but  are 
not  unfrequently  imported  by  travellers,  and  that  the  mountaineers 
look  upon  a  journey  to  Charlotte  or  Salisbury  in  autumn,  with 
much  the  same  feeling  of  apprehension  with  which  an  inhabitant 
of  either  of  these  towns  would  regard  a  visit  to  Wilmington,  or 
Washington,  on  the  seaboard. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


9 


For  some  years  past,  remittent  fever,  as  it  has  prevailed  in  the 
eastern  or  sea-board  counties  of  the  State,  has  been  almost  uni¬ 
formly  of  a  mild  type ;  very  rarely  presenting  the  severe  gastric 
and  hepatic  derangements  which  constituted  such  troublesome  and 
dangerous  complications  in  former  years. 

Thirty  years  ago,  this  form  of  fever  was  frequently  attended 
with  a  duodenitis  which  extending  along  the  hepatic  ducts  and 
their  ramifications,  caused  such  a  suspension  of  the  functions  of 
the  liver  as  to  lead  to  the  retention  of  the  elements  of  the  biliary 
secretion  in  the  blood  and  gave  to  the  skin  that  icteric  hue  which 
allied  it  closely,  both  in  the  popular  and  professional  mind,  with 
the  yellow  fever  of  the  tropics. 

As  experience  has  taught  us  that  quinine  is  entitled  to  the  rank 
of  the  febrifuge  par  excellence  in  this  form  of  fever,  we  have  been 
able,  of  late  years,  to  dispense  with  much  of  what  formerly  con¬ 
stituted  the  regular  armamentarium  medicorum  in  its  treatment. 

We  have  now  but  little  use  for  sudorifics,  effervescing  draughts, 
cold  affusion,  or  the  lancet,  and  the  disease  is  rarely  suffered  to  run 
on  long  enough  to  give  rise  to  organic  complications. 

In  cases  of  much  severity,  or  in  which  alarming  indications  pre¬ 
sent  themselves,  the  abortive  method  of  treatment  by  the  rapid 
induction  of  a  state  of  cinchonism  has  become  a  favorite  plan  of 
proceeding. 

It  has  rarely  been  found  necessary  in  this  locality  (Wilmington)? 
however,  in  order  to  produce. this  effect,  to  resort  to  the  very  large 
closes  of  the  drug,  which  have  been  recently  recommended  in  our 
medical  periodicals  and  practised  in  other  parts  of  the  State.  In 
the  vast  majority  of  cases,  which  occur  here,  the  system  may  be 
brought  sufficiently  under  its  influence,  by  doses  of  from  two  to 
five  grains  every  hour  or  two,  until  the  muffled  ear  gives  token  of 
its  peculiar  influence  upon  the  nervous  system  and  the  reduction 
of  the  excited  pulse  exhibits  its  influence  on  the  vascular  system. 

One  class  of  cases  in  which  it  is  very  desirable  if  not  indispen¬ 
sable  to  bring  the  system  very  speedily  under  the  influence  of 
quinine  is  that  which  occurs  among  children  attended  with  convul¬ 
sions  ( Febris  Remittens  Convulsiva).  In  this  class  of  cases  the  first 
and  sometimes  the  second  paroxysm  of  fever  may  be  unattended 
with  the  appearance  of  any  alarming  symptoms,  but  the  third 
paroxysm  is  apt  to  be  ushered  in  with  a  convulsion  which  seems 
to  replace  the  cold  stage  of  the  same  disease  in  adults,  and  which 
is  always  so  alarming  and  dangerous  an  occurrence,  as  to  make  it 


10 


REPORT  ON 


prudent  to  cut  short  the  disease  at  once  by  bringing  the  system 
very  rapidly  under  the  potent  influence  of  the  febrifuge. 

For  the  very  valuable  suggestion  upon  which  this  practice  is 
founded  we  are  indebted  to  Dr.  Henry  F.  Campbell,  of  Georgia. 
Detecting  the  fact  that  the  convulsion  was  but  a  chill  in  disguise, 
and  therefore  liable  like  the  chill  to  a  periodical  recurrence,  he  has 
put  us  on  our  guard  and  enabled  us  to  ward  off  an  imminent 
danger.  I  feel  assured  that  by  acting  in  accordance  with  this 
precept  I  have  been  enabled  in  a  very  large  number  of  instances) 
to  divest  this  form  of  fever  of  its  danger. 

Although  quinine  has  the.  power  of  arresting  the  progress  of 
every  variety  of  remittent  fever,  even  after  local  inflammations  and 
congestions  have  been  superinduced,  still  its  salutary  operation  is 
greatly  obstructed  by  such  occurrence.  In  cases  which  will  admit 
of  delay,  these  local  derangements  should  be  relieved  by  the  use  of 
such  local  and  general  remedies,  as  may  be  indicated  by  the  special 
complication ;  but  in  formidable  cases,  we  should  not  hesitate  to  give 
it  concurrently  with  those  remedies. 

The  ordinary  cerebral  and  lumbar  pains,  which  invariably  accom¬ 
pany  remittent  fever,  do  not  contraindicate  its  use.  On  the  con¬ 
trary  they  are  speedily  relieved  by  it,  and  in  many  cases  without 
the  use  of  those  adjuvantia  which  are  commonly  prescribed  for 
their  relief.  When,  however,  these  symptoms  are  more  than  usu¬ 
ally  violent,  or  unusually  persistent,  no  prudent  practitioner  would 
neglect  the  use  of  ancillary  measures. 

Where  there  are  evident  symptoms  of  gastritis,  as  indicated  by 
extreme  irritability  of  stomach,  especially  when  accompanied  with 
vomiting  of  a  glairy  white-of -egg -like  fluid,  local  depletion,  a  blister 
to  the  epigastrium  and  ice  ad  libitum  will  be  found  useful  prepara¬ 
tory  or  co-operative  measures. 

The  symptomatology  and  pathology  of  this  form  of  fever  so 
plainly  point  to  the  liver  as  an  organ  which  bears  in  a  large  de¬ 
gree  the  onus  of  the  malady,  as  to  make  it  important  that  we  should 
not  overlook  or  neglect  the  remedies  which  experience  has  furnished 
us  with  for  the  purpose  of  rectifying  its  disordered  functions.  , 

The  essential  anatomical  condition  of  this  form  of  fever  would 
seem  to  be,  according  to  the  views  of  Drs.  Swett,  Stewardson,  and 
Howard,  confirmed  by  the  industrious  and  careful  microscopic 
examinations  of  Dr.  Joseph  Jones,  of  Georgia,  to  be  that  condition 
of  the  liver  which  they  have  designated  by  the  term  bronzed  liver. 

Dr.  Jones,  in  his  very  elaborate  and  learned  paper  on  Malarial 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  11 

Fever,  published  in  the  twelfth  vol.  of  the  Trans,  of  the  Amer.  Med. 
Association,  attributes  this  peculiar  color  of  the  liver  “to  changes 
in  the  coloring  matter  of  the  blood,  as  is  indicated  by  the  fact  that 
the  blood  from  the  capillaries  of  the  liver  will  not  change  from  the 
dark  reddish-brown  and  purplish  color;  to  the  arterial  hue  on  ex¬ 
posure  to  the  air.  It  is  probable  that  the  altered  coloring  matter 
from  the  destroyed  disintegrated  blood-corpuscles,  or  from  the  blood- 
corpuscles  acted  on  by  the  malarial  poison  without  actual  disinte¬ 
gration,  escapes  and  permeates  the  surrounding  tissues,  and  imparts 
the  peculiar  color  to  the  liver.” 

In  the  same  valuable  paper  it  is  stated  that  the  glycogenic  func¬ 
tion  of  this  organ  is  also  frequently  impaired.  Whether  this  de¬ 
rangement  of  function  is  to  be  regarded  like  the  bronzed  color,  as 
characteristic  of  this  form  of  fever,  can  only  be  determined  by  more 
extensive  observations. 

But  whatever  may  be  the  precise  deviation  of  this  organ  from 
the  healthy  state,  experience  has  demonstrated  the  advantage  of 
such  remedies  as  are  supposed  to  possess  cholagogue  properties, 
among  which  mercurial  cathartics  rank  highest  with  the  profession 
generally. 

Though  decidedly  sceptical  with  regard  to  the  possession  of  any 
such  property  by  any  form  of  mercury,  I  still  regard  it  (but  solely 
upon  empirical  grounds)  as  a  very  valuable  medicine  for  rectifying 
disordered  hepatic  functions. 

I  have,  I  think,  occasionally  witnessed  the  sad  consequences  of 
neglecting  the  morbid  condition  of  this  viscus  and  relying  too 
exclusively  on  the  remedial  powers  of  quinine. 

The  highly  inflammatory  type  of  remittent  fever  is  rare  in  this 
locality  (Wilmington),  of  late,  and  hence  the  use  of  the  lancet  is 
seldom  required  in  its  treatment.  Instead  of  its  being  the  general 
rule  to  bleed  now,  as  it  may  be  said  to  have  been  twenty  years 
ago,  bloodletting  is  the  rare  exception  to  the  rule. 

That  bleeding  was  an  indispensable  remedy  in  the  highly  phlo¬ 
gistic  diathesis,  which  prevailed  twenty-five  years  ago,  no  man 
whose  experience  reaches  over  that  number  of  years,  will  be  likely 
to  deny. 

WThetker  the  human  constitution  has  been  so  influenced  by  the 
external  conditions  to  which  it  has  of  late  years  been  subjected,  as 
to  modify  its  morbid  manifestations ;  or  whether  the  nature  of  the 
disease  itself  through  some  occult  modification  of  its  exciting  causes, 
has  undergone  some  change,  may  not  be  very  easy  to  determine. 


12 


REPORT  ON 


But  that  a  very  decided  change  has  come  over  the  manifestation  of 
the  disease  and  the  indications  of  treatment  within  the  last  quarter 
of  a  century,  is  a  fact  testified  to  us  from  all  quarters. 

While  it  is  indisputably  true,  that  great  and  notable  advances 
have  been  made  in  the  diagnosis  of  diseases  within  the  period  under 
review,  and  we  might,  therefore,  not  unreasonably  doubt  the  accu¬ 
racy  of  the  diagnosis  of  our  predecessors,  who  depended  only  on 
the  rational  symptoms,  and  by  logical  inference  deny  the  value  of 
their  experience,  as  to  the  necessity  or  even  utility  of  the  reme¬ 
dy,  this  would  only  avail  so  far  as  regards  the  thoracic  complications 
of  the  disease ;  for,  as  a  general  rule,  although  this  disease  presents 
more  or  less  diversity  of  aspect  in  different  years,  it  rarely  changes 
its  phasis  to  such  an  extent  as  to  render  its  diagnosis  a  matter  of 
difficulty. 

We  are  not,  therefore,  warranted  in  condemning  the  practice  or  in 
ignoring  the  experience  of  the  age  which  has  just  preceded  us;  nor 
in  pluming  ourselves  on  any  demonstrated  superiority  in  practice- 
Another  cycle  of  twenty  or  thirty  years  may  lead  our  successors 
to  wonder  at  what  they  may  have  good  reason  to  regard  as  our 
weak  and  inefficient  methodus  medendi. 

That  the  type  of  disease  varies,  from  year  to  year,  or  within  a 
series  of  years,  is  a  proposition  which  has  received  the  very  general 
assent  of  the  profession  since  the  days  of  Sydenham ;  and  although 
we  may  regard  his  ascription  of  it  to  some  occult  atmospheric  con¬ 
stitution,  as  but  a  hypothetical  solution  of  the  problem,  it  will  not 
be  wise  to  disregard  the  great  amount  of  observation  and  experi¬ 
ence  which  has  since  been  accumulated  upon  this  point,  and  to  con¬ 
clude  that  because  bloodletting  does  not  now  seem  to  be  a  sine  qua 
non  in  the  treatment  of  inflammatory  disorders,  that  it  never  has 
been  entitled  to  be  so  regarded. 

Extreme  opinions  on  medical,  as  on  many  other  subjects,  rarely 
stand  the  test  of  time  and  experience,  and  though  the  aphoristic 
words  of  Hippocrates,  “ experientia  fallax  judicium  difficile”  embo¬ 
dies  a  desponding  truth,  experience  must,  I  presume,  still  be  re¬ 
garded,  as  the  great  arbiter  both  of  opinion  and  practice. 

The  congestive  and  adynamic  types  of  remittent  fever  have  been 
of  very  rare  occurrence  of  late  years,  in  the  maritime  counties  of 
the  State;  but  the  interior  and  middle  districts  of  the  State  have 
not  enjoyed  a  similar  exemption  from  these  grave  forms  of  fever. 
Dr.  N.  I.  Pittman,  of  Edgecombe  County,  reports,  “ that  during  the 
year  1857,  we  have  had,  in  Edgecombe  County,  bilious  remittent 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  13 

fever  to  prevail  more  generally  than  it  had  done  for  the  preceding 
eight  years.  Our  summer  and  autumn  were  unprecedentedly  hot 
and  dry,  the  spring  months  having  been  cool  and  wet.  The  type 
of  fever  which  has  prevailed  with  us  since  the  spring  of  1855,  has 
been  of  a  continued  character,  assuming  often  a  typhoid  or  ady¬ 
namic  form;  and  occasionally  we  have  had  genuine  idiopathic 
typhoid  fever,  answering  admirably  to  the  descriptions  of  Louis, 
Wood,  Stokes,  and  others. 

“In  the  treatment  of  the  bilious  remittent  fever  which  visited  our 
section  of  the  country,  there  was  no  special  or  novel  practice  insti¬ 
tuted.  We  relied  principally  upon  mercurial  cathartics,  quinine, 
cinchona,  diaphoretics,  blisters  to  the  epigastrium,  nape  of  the  neck, 
and  spine,  as  symptoms  seemed  to  demand.” 

Dr.  H.  Kelley  reports  the  prevalence  of  remittent  and  intermit¬ 
tent  fevers,  in  the  County  of  Iredell,  in  the  western  part  of  the 
State.  These  diseases  prevailed  to  a  considerable  extent,  in  the 
neighborhood  of  large  watercourses.  Dr.  Otis  Frederick  Manson, 
of  Granville  County,  gives  us,  in  a  paper  read  before  the  N.  C. 
Med.  Society  in  1856,  a  description  of  the  adynamic  and  congestive 
varieties  of  remittent  fever  as  they  prevailed  in  that  section  of  the 
State,  from  which  I  extract  as  follows : — 

Adynamic  Remittent. — Remittent  fever  of  a  low  grade,  and  per¬ 
sistent  character,  strongly  simulating  continued  fever,  may  present 
itself  as  a  sequel  to  neglected  or  mismanaged  cases  of  the  ordinary 
form  of  the  disease,  or  may  occur  primarily. 

Its  approach  is  commonly,  however,  less  abrupt  than  the  usual 
form,  the  invasion  being  often  unattended  by  a  decided  chill.  In 
other  respects  the  prodromise  do  not  differ  essentially  from  an  ordi¬ 
nary  attack.  The  pulse  is  of  ordinary  frequency,  not  usually  ex¬ 
ceeding  100  per  minute  in  adults.  The  exacerbations  and  remis¬ 
sions  are  indistinctly  marked,  the  pulse  in  many  cases  varying 
only  eight  or  ten  beats  in  twenty-four  hours.  The  heat  of  skin  is 
moderate,  and  very  often  attended  with  some  moisture,  during  the 
greater  period  of  the  attack.  When  the  disease  is  fully  formed, 
the  tongue  becomes  more  or  less  pointed  and  red  at  its  tip,  and  on 
its  edges,  with  a  brown  fur  on  its  dorsum.  The  patient  does  not 
usually  experience  much  acute  pain.  A  dull  headache,  but  not 
continuous,  together  with  some  abdominal  uneasiness,  is  generally 
present.  Diarrhoea  sometimes  occurs,  and  although  it  may  be  absent, 
a  tendency  towards  it  is  manifested  by  a  morbid  susceptibility  to 
the  action  of  cathartics ;  the  mildest  aperients  producing  severe 

9 


14 


REPORT  ON 


tormina,  and  frequent  copious  serous  discharges.  As  the  disease 
advances,  the  tongue  becomes  dry,  brown,  and  even  black,  or  part¬ 
ing  with  its  coat,  it  presents  a  clean,  red,  shining  surface.  The  ab¬ 
domen  becomes  tympanitic,  tense,  and  tender  to  the  lightest  touch, 
or  as,  in  some  cases,  although  enlarged,  yet  it  is  soft,  its  walls 
yielding  to  the  weight  of  the  viscera  ;  the  skin  being  wrinkled, 
dry,  and  desquamating,  and  the  separate  and  relaxed  muscular 
fibres  imparting  a  sensation  to  the  hand  as  if  the  cavity  was  filled 
with  lumbrici.  The  mind  is  usually  clear,  in  the  first  stages  ;  as  the 
disease  advances,  however,  the  intellect  yields.  Continuous  mutter¬ 
ing  delirium,  colliquative  diarrhoea,  and  sometimes  intestinal  he¬ 
morrhage  supervene  (the  blood  in  the  latter  instance  being  fluid, 
uncoagulable  and  horribly  offensive),  under  which  the  patient  soon 
succumbs. 

Grave  Remittent  Fever. — (Synonyms  :  Congestive  Fever  /  Per¬ 
nicious  Fever ;  Algid  Fever)  Dr.  Manson  continues:  We  now  pro¬ 
ceed  to  describe  a  grade  of  remittent  fever  that  may  be  justly 
ranked  with  the  most  fearful  and  fatal  scourges  which  afflict  hu¬ 
manity.  In  the  phases  of  this  affection,  predescribed,  nature  seems 
to  have  resisted  the  action  of  the  morbific  cause  with  energy  and 
promptness,  but  in  this  the  vital  power  seems  overwhelmed  and 
powerless  and,  unassisted,  too  often  surrenders. 

Grave  remittent  may  occur  as  a  primary  form  of  disease,  or,  as 
more  generally  the  case  in  this  region,  it  commences  with  the 
symptoms  of  mild  remittent  or  intermittent  fever,  when  either  from 
its  natural  cause,  or  more  frequently  from  exposure,  or  improper 
treatment,  such  as  ill-timed  depletion  or  purgation,  it  suddenly 
presents  the  graver  and  alarming  symptoms  which  characterize  it ; 
the  most  conspicuous  of  which  are  a  prolonged  cold  stage  and 
failure  or  disappearance  of  the  pulse.  The  symptoms,  however,  in 
other  respects,  often  widely  vary,  and  in  my  opinion  may  be  classed 
under  three  heads,  viz:  Those  referable  to,  and  arising  from,  a 
perverted  action  of  different  portions  of  the  cerebro-spinal  axis,  as 
follows :  1st.  Symptoms  arising  from  congestion  of  the  cerebrum  ; 
2d.  Those  arising  from  congestion  of  the  cerebellum,  pons  varolii 
and  medulla  oblongata;  and  3d.  Those  arising  from  congestion  of  the 
spinal  cord.  We  deem  it  proper  to  describe  the  symptoms  pre¬ 
sented  in  all  these  modifications. 

The  phenomena  which  forcibly  arrest  the  attention  of  the  observer 
are  those  presented  by  the  state  of  the  skin,  and  the  pulse.  The 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


15 


patient  is  cold,  the  features  are  sharp  and  shrunken,  and  the 
surface  is  shrivelled.  In  some  cases  it  is  merely  pale,  but  in  the 
worst  cases,  the  skin  is  of  a  dusky  purplish  hue.  It  may  be  dry, 
but  usually  it  is  damp,  or  even  wet,  with  exhalation,  which  is  some¬ 
times  glutinous  in  its  character;  it  may  be  deficient  in  sensibility, 
to  such  an  extent  that  the  common  external  irritants,  such  as  rube¬ 
facients,  sinapisms  and  blisters,  produce  no  impression.  This  con¬ 
dition  of  skin  may  exist  over  the  whole  body,  but  usually  within  my 
observation,  it  does  not  pervade  the  trunk,  being  confined  to  the 
upper  and  lower  extremities,  the  nose,  cheeks  and  ears,  the  rest  of 
the  head  and  body  being  of  febrile  heat.  The  pulse  is  very  fre¬ 
quent  and  small,  and  in  some  rare  instances  disappears  entirely 
from  the  wrist.  The  respiration  is  more  or  less  disturbed.  The 
patient  complains  of  a  sense  of  oppression  about  his  chest;  he  sighs 
often,  suffers  from  sensations  of  internal  heat,  demands  cold  drink, 
desires  to  be  fanned,  and  strenuously  objects  to  any  covering  being 
placed  on  his  clay-cold  limbs.  The  cardiac  sounds  and  impulse  are 
normal,  and  in  some  cases  more  distinct  than  in  health  when  the 
coldness  of  the  surface  is  confined  to  the  extreme  parts,  but  when  it 
pervades  the  whole  periphery  the  sounds  and  impulse  are  indistinct 
and  feeble.  The  strength  of  the  patient  is  often  remarkable,  so  that 
he  is  able  to  assist  himself,  and  even  to  walk  about  his  room  for 
some  time. 

Diarrhoea  is  sometimes  present,  but  is  not  a  constant  symptom. 
The  duration  of  the  cold  stage  varies  very  much,  but  it  rarely  con¬ 
tinues  beyond  eight  or  ten  hours;  it  however  may  endure  much 
longer. 

Exacerbation. — The  reaction  may  be  perfect  or  partial.  The  heat 
gradually  returns  to  the  surface,  and  extends  to  the  extremities;  the 
pulse  becomes  less  frequent  and  more  expanded ;  the  breathing 
becomes  disembarrassed;  the  symptoms  common  to  the  milder 
grade  being  present  in  ratio  with  the  development  of  the  febrile 
action.  This  stage  endures  from  ten  to  twenty-four  hours,  and  is 
succeeded  by  a  stage  of  congestion,  which  in  turn  yields  to  a  re¬ 
action  more  or  less  distinct,  or  is  fatal,  the  disease  having  a  tendency 
to  terminate  on  the  third,  fifth,  and  seventh  days  mortally,  or  sub¬ 
siding  into  the  mild  form,  or  into  intermittent  fever. 

Congestion  of  the  Cerebrum.  The  cold  stage. — The  patient  may  be 
suddenly  seized  with  the  symptoms  of  inordinate  sanguineous  de¬ 
termination  to  the  superior  portion  of  the  encephalon,  but  usually 
there  are  some  premonitions.  He  complains  of  pain  in  the  frontal 


16 


REPORT  ON 


region  of  an  acute  throbbing  character;  the  intellect  is  confused 
and  wandering,  and  he  is  disposed  to  sleep,  the  drowsiness  gradu¬ 
ally  increasing  to  coma.  He  seems  to  be  in  a  profound  sleep,  but 
sometimes  can  be  aroused  by  shaking  forcibly,  and  calling  aloud, 
when  he  may  reply  in  monosyllables  and  intelligibly,  but  instantly 
sinks  into  stupor  again.  He  breathes  softly,  regularly,  and  but 
little  more  frequently  than  in  health.  His  extremities  are  cold  and 
of  a  bluish  tint,  the  coldness  extending  to  the  pelvis  and  axillae, 
the  trunk  and  head  being  of  febrile  warmth.  In  some  instances  the 
whole  surface  is  cold,  but  this  is  rare.  The  skin  is  usually  dry  or 
but  slightly  moist,  this  variety  not  being  usually  attended  with 
colliquative  sweat.  The  pulse  is  frequent  and  small. 

The  exacerbation. — The  pulse  still  indicates  evidences  of  an  im¬ 
peded  circulation  and  rarely  regains  its  normal  volume  or  force, 
the  breathing  becomes  more  accelerated,  the  patient  grows  restless, 
and  gradually  regains  his  faculties.  He  now  complains  of  cephalic 
pain,  of  nausea,  and  occasionally  vomits,  and  the  whole  surface  be¬ 
comes  warm  and  even  hot.  As  the  exacerbation  declines,  the 
patient  becomes  more  comfortable,  and  himself  and  friends  look 
forward  to  a  speedy  convalescence ;  but  this  is  a  deceitful  calm. 
The  cold  stage  recurs  with  aggravation  of  the  cerebral  symptoms 
and  increased  prostration  of  the  general  powers.  In  some  cases, 
however,  without  assistance,  the  second  cold  stage  assumes  a  miti¬ 
gated  character,  gradually  subsiding  into  a  mild  remittent,  or  inter¬ 
mittent  form.  When  the  disease,  however,  continues  unabated,  the 
third  paroxysm  is  prone  to  prove  fatal,  but  the  termination  may  be 
postponed  to  a  more  advanced  period. 

Congestion  of  the  Cerebellum ,  &c.  The  cold  stage. —  Unlike  the 
variety  just  described,  the  intellectual  functions  in  this  are  undis¬ 
turbed.  The  patient  complains  of  fixed  pain  in  the  occipital  region, 
is  very  restless,  constantly  shifts  his  position,  complains  of  great 
difficulty  of  breathing,  and  often  declares  “  he  will  die  for  want  of 
air.”  He  experiences  a  distressing  sense  of  internal  heat  and  op¬ 
pression.  The  respiration  is  irregular  and  laborious,  the  expira¬ 
tions  being  forcible  and  prolonged.  (By  some,  these  symptoms 
have  been  attributed  to  pulmonary  engorgement,  but  it  is  now 
known,  that  the  lungs  after  death  very  rarely  present  the  slightest 
indication  of  such  a  condition  having  existed;  the  dyspnoea  is 
therefore  evidently  owing  to  impeded  innervation,  and  this  pro¬ 
ceeding  from  a  congested  condition  of  the  vessels  of  the  cerebellum.) 
The  skin  is  cold,  of  a  purple  and  mottled  appearance,  bedewed  with 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


17 


moisture.  This  state  of  the  surface  is  usually  confined  to  the  ex¬ 
tremities,  the  remaining  surfaces  being  above  the  natural  tempera¬ 
ture.  The  tongue  is  dusky  and  expanded,  and  in  extreme  cases, 
it  is  cold,  as  well  as  the  breath.  The  bowels  are  generally  sluggish, 
but  the  urine  is  copious  and  limpid.  The  patient  often  arises  from 
his  bed,  but  his  gait  is  tottering  and  unsteady ,  and  he  sometimes  falls 
to  the  floor  suddenly,  as  if  stricken  lifeless,  but  instantly  arises 
again  ;  thereby  proving  that  it  is  not  simply  from  debility  that  he 
is  unable  to  retain  the  erect  position,  but  from  a  loss  of  control  over 
his  muscular  movements.  The  pulse  is  very  frequent  and  small ; 
nausea  is  not  usually  present,  but  the  patient  makes  frequent  efforts 
to  vomit,  thinking  thereby  to  remove  the  thoracic  oppression. 
Insensibility  of  the  stomach  to  the  action  of  medicine,  is  a  promi¬ 
nent  condition  in  this  stage,  which  rarely  endures  for  more  than 
ten  hours. 

The  exacerbation. — The  reaction  gradually  ensues,  and  in  propor¬ 
tion  to  its  development,  the  symptoms  belonging  to  the  cold  stage 
disappear.  The  respiration  becomes  more  regular  and  free,  the 
pulse  slower  and  expanded,  the  skin  becomes  warm  and  even  hot, 
and  the  pain  in  the  occipital  region  mitigated;  nausea  and  vomit¬ 
ing  are  apt  to  ensue,  and  the  stomach  responds  to  the  action  of 
medicine  readily.  Without  interference  the  cold  stage  again  occurs, 
the  second  paroxysm  often  proving  fatal. 

Spinal  Congestion.  The  cold  stage. — This  is  attended  with  symp¬ 
toms  of  a  milder  character,  and  is  of  shorter  duration  than  the 
preceding  varieties  of  the  grave  form.  The  spinal  pain  is  confined 
to  the  dorsal  and  lumbar  regions,  and  is  not  of  an  acute  character, 
save  when  pressure  is  made  on  the  affected  region.  Unlike  the 
former  varieties,  in  this  the  intellect  is  unaffected  and  the  respira¬ 
tion  free. 

The  diminished  temperature  is  usually  confined  to  the  extremi¬ 
ties,  and  rarely  extends  beyond  the  knee  and  elbow,  nor  is  there 
usually  present  any  superabundance  of  moisture,  the  cold  surface 
being  dry  or  merely  damp,  the  remaining  surface  (always  excepting 
the  facial  extremes)  being  above  the  natural  heat.  The  patient 
(in  this  as  in  the  former  varieties)  is  ignorant  of  the  coldness  of 
the  extremities,  and  complains  of  heat,  is  restless  and  suffers 
violently  from  spasmodic  pain  in  hisboivels,  which  are  usually  costive. 
To  such  an  extent  are  the  abdominal  pains  present,  that  the  dis¬ 
ease  has  been  mistaken  for  an  attack  of  colic.  The  pulse  is  not 
usually  much  accelerated,  but  is  irregular  during  the  paroxysm  of 


18 


REPORT  ON 


abdominal  pain.  This  stage  rarely  exceeds  one  or  two  hours  in 
duration. 

The  exacerbation. — Although  the  reaction  is  usually  decided,  the 
fever  is  rarely  intense.  The  skin  becomes  warm  and  expanded, 
and  often  moist.  The  pulse,  unlike  as  occurs  in  the  former  varie¬ 
ties,  now  usually  becomes  morbidly  sloiv  and  is  characteristic  of  this 
phase  of  remittent.  This  condition  of  the  pulse,  unless  observed 
and  counted,  is  apt  to  throw  the  inexperienced  off  their  guard.  I 
have  known  physicians  of  no  mean  skill,  declare  that  the  patient 
was  but  slightly  ill,  who  nevertheless  expired  in  the  next  paroxysm. 
More  or  less  tenderness  will  be  found  on  pressure  of  the  abdomen, 
chiefly  in  the  umbilical  region,  but  the  spasmodic  pains  are  always 
mitigated,  and  sometimes  entirely  disappear  in  this  stage,  which  is 
more  prolonged  than  in  the  other  varieties.  A  complete  remission, 
late  in  the  night,  or  during  the  morning  hours,  often  ensues,  in 
which  the  patient  sleeps  quietly,  and  presents  so  few  marked  indi¬ 
cations  of  disease,  as  to  attract  but  little  attention.  The  cold  stage 
however  reappears,  attended  with  more  aggravated  symptoms.  The 
abdomen  becomes  enlarged  and  exquisitely  tender,  and  the  ago¬ 
nizing  abdominal  pains  return. 

As  the  disease  advances,  the  abdomen  becomes  tympanitic;  serous, 
or  as  is  more  often  the  case,  hemorrhagic  discharges  ensue,  the 
blood  being  black,  liquid,  and  offensive ;  the  coldness  extends  over 
the  whole  surface,  a  clammy  sweat  breaks  out,  the  features  become 
cadaveric,  and  the  patient  sinks  into  coma  and  expires.  The  fatal 
termination  is,  however,  usually  postponed  beyond  the  seventh  day. 

Diagnosis. — A  well  marked  case  of  either  disease  would  rarely 
be  mistaken  by  an  observer  of  ordinary  perception ;  but  under 
the  head  of  adynamic  remittent,  we  have  endeavored  to  depict 
a  form  which  bears  enough  resemblance  to  typhoid  fever  to  be 
often  confounded  with  it.  Like  typhoid  fever,  adynamic  remittent 
may  appear  at  any  season  of  the  year.  It  is  rarely  attended  with 
much  acute  suffering,  and  is  protracted  in  its  duration.  The  resem¬ 
blance  is  rendered  more  striking  by  the  evidences  of  abdominal 
lesion  in  both,  the  tongue  being  inclined  in  either  to  be  red  and 
dry,  and  diarrhoea  aud  meteorism  being  symptoms  common  to  both. 
Here,  however,  we  think  the  analogy  ends.  In  remittent  there  is 
an  absence  of  that  peculiar,  stupid,  vacant  expression,  deafness,  and 
the  irregular  exacerbations  of  continued  fever. 

Epistaxis  and  sudamina,  so  continually  present  in  typhoid,  are 
rare  in  remittent  fever.  The  chill  of  remittent  differs  from  that 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


19 


of  any  other  disease  whatever.  In  typhoid  fever,  there  is  a  pecu¬ 
liar  condition  of  the  patient,  which,  as  we  have  never  seen  dis- 
cribed,  we  think  it  proper  to  notice.  The  patient  complains  of  a 
sensation  of  intense  cold,  and  in  some  instances  will  shiver  as  with 
an  ague.  These  nervous  shudderings,  or  instances  of  extreme 
nervous  irritation  as  we  deem  them,  may  occur  frequently  during 
the  day  or  night  with  great  irregularity,  disappearing  for  several 
days  together,  and  then  returning  again.  So  far  as  our  observation 
extends,  these  rigors  are  unattended  with  the  slightest  diminution 
of  the  temperature  of  any  part,  the  whole  surface  being  rather 
above  the  normal  standard,  even  to  the  most  extreme  parts;  indeed 
we  have  noticed  these  paroxysms  to  occur  in  many  instances, 
when  the  patients  were  in  a  warm  perspiration.  It  is  worthy  of 
notice  that  these  chills  (as  writers  term  them)  are  not  followed  by 
any  perceptible  increase  of  febrile  excitement,  which  is  an  invaria- 
able  sequent  of  the  chill  of  remittent.  The  pulse,  although  fre¬ 
quent  in  both  diseases  yet  is  attended  with  fluctuations,  so  differ¬ 
ent  from  each  other,  in  the  respective  fevers,  as  to  present  a  most 
invaluable  aid  in  diagnosis.  Cullen,  Parr,  Good,  and  others,  have 
declared  that  in  continued  fever,  there  are  two  diurnal  exacerba¬ 
tions,  whilst  in  remittent  there  is  only  one.  We  have  often  veri¬ 
fied  the  truth  of  their  distinction,  and  we  feel  assured  that  in 
doubtful  cases,  the  peculiar  character  of  the  fever  may  be  detected 
by  this  test.  The  pulse  should  be  counted  at  short  and  regular 
intervals  throughout  the  day  and  night.  If  the  case  is  continued 
fever  it  will  rise  and  decline  twice,  the  first  exacerbation  occur- 
ring  in  the  morning,  and  the  second  in  the  afternoon,  or  night. 
In  remittent,  only  one  exacerbation  will  thus  be  discovered. 

The  perspiration  and  urine  have  a  peculiar  odor  in  typhoid, 
which  I  have  never  observed  in  remittent  fever.  The  intestinal 
evacuations  are  infinite  in  their  varieties,  in  both  diseases,  but 
there  is  a  discharge  of  a  peculiar  character  in  typhoid,  which  I 
have  never  seen  in  remittent.  It  is  of  a  shining,  reddish-brown 
appearance,  about  the  consistence  of  molasses,  and  seems  glutinous 
in  its  nature,  adhering  to  the  side  of  the  vessel,  and  is  very  offen¬ 
sive.  The  viscid,  green-black,  inodorous,  bilious  evacuations,  which 
almost  certainly  indicate  a  favorable  termination  in  remittent,  I 
have  never  seen  in  typhoid  fever.  In  the  latter  disease,  healthful 
and  perfect  digestion  often  returns,  and  natural  and  consistent 
feces  are  evacuated,  sometimes  before  the  disappearance  of  febrile 
excitement.  These  we  have  never  witnessed  in  remittent,  until 


20 


REPORT  ON 


convalescence  was  established.  Intestinal  hemorrhage  is  often  pre¬ 
sent  during  the  course  of  typhoid  fever,  but  as  a  rule,  attends  only 
the  termination  of  remittent.  In  the  former,  it  is  often  salutary, 
the  blood  being  of  a  bright-red  color,  coagulable  and  healthy  in 
appearance.  In  the  latter,  it  is  fluid,  black,  and  offensive,  and  is 
usually  indicative  of  a  fatal  termination.  I  have  not  thought 
proper  to  recapitulate  all  the  diagnostic  signs  known,  which  would 
be  proper  in  a  treatise,  but  supererogatory  in  a  contribution.  It 
is  believed  that  the  foregoing  will  almost  invariably  enable  the 
practitioner  to  detect  the  proper  character  of  the  case. 

Treatment  of  Mild  Remittent.  In  the  exacerbation. — If  the  pulse  is 
hard  or  full,  and  resisting,  especially  if  attended  with  intense  cere¬ 
bral  or  spinal  pain,  a  moderate  bleeding  from  the  arm  will  produce 
great  relief,  but  this  will  be  very  rarely  necessary.  Local  bleeding 
will  be  generally  found  sufficient,  and  is  an  invaluable  adjunct. 
Leeches  to  the  temple,  or  cups  to  the  occipital  or  spinal  regions, 
may  be  freely  applied,  as  the  determination  may  indicate.  If  nausea 
or  vomiting,  or  other  symptoms  of  gastric  irritation  be  present, 
leeches  or  cups  to  the  epigastrium  will  be  followed  by  great  relief; 
and  if  these  should  be  succeeded  by  a  simple  enema,  under  their 
conjoined  action,  the  bowels  will  gently  respond,  and  add  greatly 
to  the  comfort  of  the  patient. 

Cold  drinks,  ice,  the  effervescing  draught  and  lemonade,  may  be 
freely  allowed.  At  bedtime — say  at  nine  or  ten  o’clock — it  is  al¬ 
most  our  invariable  rule  to  administer  a  cathartic  dose  of  calomel 
and  rhubarb,  of  ten  or  twelve  grains  each.  At  some  period,  before 
or  after  midnight,  the  fever  will  generally  be  found  more  or  less 
to  decline.  We  prefer  this  period  for  the  commencement  of  the 
abortive  means,  because  our  experience  convinces  us  that  quinine, 
the  principal  remedy,  is  then  better  borne,  and  produces  its  salu¬ 
tary  effects  in  a  more  decided  and  complete  manner,  than  at  any 
other  time. 

We  now,  therefore,  usually  administer  from  ten  to  twenty  grains 
of  quinine  at  a  single  dose,  in  pills  or  diffused  in  a  wineglassful  of 
water.  We  regulate  the  dose  by  the  degree  of  fever  present. 
If  it  is  intense,  we  administer  the  larger  quantity;  if  very  mode¬ 
rate,  the  lesser  will  answer.  Under  the  combined  action  of  the 
mercurial  and  quinine,  free  evacuation  of  the  bowels  will  usually 
occur,  but  rarely  excessive.  Three  or  four  hours  are  now  suffered 
to  elapse,  during  which  the  topical  bleeding  is  repeated,  if  the  local 
symptoms  do  not  yield.  The  condition  of  the  patient  will  now  be 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


21 


found  generally  much  improved.  The  cerebro-spinal  pain  is  either 
removed  or  mitigated,  the  pulse  less  frequent,  and  more  soft,  the 
skin  relaxed  and  moist,  and  the  gastric  irritation  subdued.  We, 
therefore,  repeat  the  quinine,  in  diminished  doses  of  five  or  six 
grains  every  three  or  four  hours,  until  the  period  of  chill  has 
passed,  generally  exhibiting  from  twenty-five  to  forty  grains  be¬ 
fore  that  time.  In  cases  attended  with  much  gastric  irritation,  or 
diarrhoea,  the  addition  of  a  full  dose  of  opium — say  one  and  a  half 
to  two  grains,  to  ten  or  twelve  grains  of  the  submuriate,  at  bed¬ 
time,  instead  of  the  rhubarb — forms  an  excellent  combination, 
which  will  enable  the  stomach  to  retain  the  quinine  afterwards  ad¬ 
ministered,  with  more  certainty.  Under  this  plan,  remittent  fever, 
as  it  appears  usually  in  this  section,  is  certainly  and  safely  cured. 
We  have,  in  this  manner,  arrested  the  disease  in  many  hundred 
cases,  in  one  night.  Owing,  however,  to  the  peculiar  liability  of 
the  affection  to  relapse,  or  terminate  in  protracted  intermittent,  we 
usually  continue  the  treatment.  We  think  it  advisable  to  prescribe 
a  mercurial  alterative  of  calomel  or  mass  hydrarg.  for  two  or  three 
successive  nights,  followed  by  eight  or  ten  grains  of  quinine,  or 
twenty-five  drops  of  oil  of  turpentine,  in  divided  doses,  on  the  suc¬ 
ceeding  mornings.  In  cases  attended  with  coma,  delirium,  or  con¬ 
vulsions,  during  the  exacerbation,  topical  bleeding  will  be  freely 
required,  and  the  application  of  cold.  We  have,  however,  been 
more  gratified  with  the  effects  of  the  cold  douche ,  in  these  compli¬ 
cations,  than  with  any  other  remedy.  A  full  dose  of  calomel 
should  be  given,  followed  by  stimulating  enemata. 

In  the  form  described  under  the  title  of  adynamic  remittent, 
occurring  as  a  primary  form,  this  mode  of  treatment  will  usually 
suffice;  but  in  protracted  cases,  a  different  practice  will  be  found 
necessary,  as  quinine  is  not  borne  well,  and  the  antiphlogistic  re¬ 
medies  detailed  are  contra-indicated.  Minute  doses  of  calomel 
combined  with  opium,  will  usually  be  found  of  great  service  along 
with  the  employment  of  the  oil  of  turpentine,  which  may  almost 
be  regarded  as  a  specific  in  this  variety.  It  is  more  suitable  in 
this  condition  than  quinine,  as  it  is  better  tolerated;  and  while 
it  possesses  febrifuge  properties  very  similar  to  the  alkaloid, 
it  also  exerts  a  happy  influence  over  the  gastric  and  intestinal 
irritation  so  commonly  present.  It  may  be  given  in  doses  of  ten 
to  twenty  drops  in  emulsion,  repeated  every  three  or  four  hours 
until  the  symptoms  yield.  It  should  be  persisted  in  until  the  pa¬ 
tient  is  fairly  under  its  influence,  unless  the  effects  it  occasionally 


22 


REPORT  ON 


produces,  viz:  hsematuria,  strangury,  or  its  peculiar  intoxication 
supervene,  when  of  course  it  should  be  discontinued.  It  would 
require  too  much  space  to  speak  of  this  remedy  in  this  place  as  it 
deserves. 

Treatment  of  Grave  Remittent.  The  cold  stage. — In  this  grade,  ex¬ 
ternal  means  are  all-important.  W arm  applications  are  to  be 
assiduously  made  to  the  parts  reduced  in  temperature,  together 
with  stimulating  frictions.  These  should  be  freely  applied  to  the 
whole  length  of  the  spinal  column  and  to  the  extremities.  A  large 
blister  should  be  placed  over  the  epigastrium,  and  if  the  head  is 
affected,  another  to  the  nape  of  the  neck. 

Medicine. — To  produce  reaction  along  with  these  applications  I 
prefer  enemata  of  quinine.  The  plan  preferred  is  to  dissolve  ten 
grains  in  a  wineglassful  of  weak  infusion  of  capsicum,  with  the 
addition  of  a  few  drops  of  elixir  vitriol.  This  is  thrown  up  the 
rectum  every  half  hour  until  reaction  ensues.  If  diarrhoea  has  been 
or  is  present,  I  prefer  enemata  of  quinine  and  laudanum.  By  these 
means  alone,  cases  apparently  hopeless  have  been  rescued.  In  a 
case  of  very  protracted  cold  stage,  a  combination  of  one  grain  of 
calomel,  one  of  quinine,  and  one-fourth  of  a  grain  of  opium,  together 
with  frequent  doses  of  camphor  water,  induced  a  speedy  reaction. 
The  oil  of  turpentine,  in  spinal  congestion,  is  also  an  excellent  re¬ 
medy.  Ten  or  fifteen  drops,  alone  or  combined  with  laudanum, 
may  be  given  every  hour  or  two,  or  more  frequently. 

The  exacerbation. — The  reaction  is  sometimes  intense.  When 
this  occurs,  I  have  ventured  on  the  abstraction  of  blood  from  the 
arm  in  moderate  quantity  with  decided  benefit ;  but  this  is  seldom 
necessary.  The  case  only  requires  to  be  treated  as  the  milder 
grade,  save  perhaps  with  a  more  liberal  use  of  quinine.  A  mode¬ 
rate  dose  of  calomel  (ten  or  fifteen  grains),  alone  or  combined  with 
one  or  two  grains  of  opium,  if  there  be  much  gastric  irritation  or 
diarrhoea,  is  followed  in  two  or  three  hours  by  a  full  dose  of  qui¬ 
nine  (twenty  grains),  and  repeated  in  doses  of  five  or  ten  grains 
every  three  or  four  hours,  until  thirty-five  or  forty  grains  are  taken. 
The  medicine  should  be  so  regulated,  that  the  last  dose  may  be 
taken  two  or  three  hours  before  the  expected  paroxysm.  I  have 
never  seen  a  chill  or  cold  stage  recur  after  forty  grains  of  Farr’s 
quinine  has  been  retained.  Although  the  patient  may  generally  be 
considered  out  of  danger  when  the  paroxysms  have  been  arrested, 
yet  I  esteem  it  good  practice  to  prevent  a  relapse,  by  placing  the 


THE  EPIDEMICS  OF  NOETH  CAROLINA. 


23 


patient  on  a  gentle  alterative  course,  and  to  repeat  the  quinine  in 
diminished  quantity  for  several  days  thereafter. 

The  foregoing  graphic  and  discriminating  description  of  the 

several  forms  of  remittent  fever  as  they  appear  in  Granville  and 

the  adjacent  counties,  may  perhaps  be  fairly  regarded  as  applicable 

to  the  entire  middle  district  of  the  State.  Dr.  Manson’s  report  is 

silent  upon  the  point  of  the  comparative  frequency  of  the  graver 

types  of  the  disease.  If  they  constitute  any  considerable  portion 

of  the  cases  which  occur,  if  they  are  not  very  rare  exceptions  to 

* 

the  great  mass  of  cases,  it  would  be  fair  to  infer  that  the  cause  or 
causes  which  give  rise  to  this  form  of  fever,  exist  in  greater  po¬ 
tency  in  the  elevated  region  of  the  interior  of  the  State,  than  in  the 
low  paludal  districts  of  the  seaboard.  It  is  true,  that  we  occasion¬ 
ally  meet  in  the  tide-water  counties,  but  little  elevated  above  the 
level  of  the  ocean,  with  cases  corresponding  exactly  with  his  ad¬ 
mirable  delineation  of  the  features  of  the  graver  forms  of  the  ma¬ 
lady  ;  but  these  cases  are  exceedingly  few  compared  with  the  very 
large  number  of  the  milder  forms. 

The  congestive  type  of  the  disease,  though  occurring  more  fre¬ 
quently  in  some  years  than  in  others,  can  hardly  be  said  to  have 
constituted  the  prevailing  type  for  many  years  past,  if  ever. 

TYPHOID  FEVER. 

This  disease  first  began  to  prevail  in  the  interior  of  the  State, 
and,  as  well  asl  have  been  able  to  discover,  in  the  counties  border¬ 
ing  on  the  State  of  Virginia,  and  was  for  a  long  time  regarded  by 
the  dwellers  in  the  low  country  as  an  up-country  disease.  For  a 
series  of  years  it  seemed  to  be  limited  in  its  range,  but  has  gradu¬ 
ally  spread  in  all  directions,  until  it  has  come  to  occupy  the  entire 
area  of  the  State,  from  the  mountains  to  the  seaboard ;  the  eastern 
or  seaboard  counties,  being  the  last  to  be  brought  within  the  sphere 
of  its  influence.  It  would  thus  appear  to  be  but  little  influenced 
by  the  climatic  or  local  conditions  which  obtain  within  the  boun¬ 
daries  of  the  State.  It  has  made  a  local  habitation  on  the  very 
summit  of  the  Blue  Kidge,  and  a  dwelling-place  in  the  swamps  of 
the  seacoast.  Neither  high  nor  low  temperature  exert  much  influ¬ 
ence  over  it,  for,  though  the  worst  forms  of  it  occur  in  mid-winter, 
it  also  prevails  during  the  greatest  heat  of  the  summer  months. 

Without  entering  into  the  vexed  question  of  its  etiology  or  oc¬ 
cupying  space  with  an  attempt  at  the  portraiture  of  the  disease, 


24 


REPORT  ON 


which  has  been  so  often  and  so  ably  depicted  in  its  varying  aspects 
and  minutest  features,  I  proceed  to  report  such  practical  matter  as 
I  have  been  able  to  procure  upon  the  subject. 

Dr.  M.  Whitehead,  of  Salisbury,  reports,  that  during  the  last 
twelve  months,  we  have  been  remarkably  exempt  from  remittent 
and  intermittent  fevers,  but  have  had  an  epidemic  of  typhoid  fever. 

Within  the  last  few  years,  the  character  of  our  fevers  has  under¬ 
gone  a  marked  change.  The  periodic  fevers,  which  once  main¬ 
tained  such  an  overwhelming  preponderance  in  our  cases,  and  were 
the  endemic  fevers  of  the  country,  have  given  place,  in  a  very  great 
degree,  to  this  form  of  continued  fever.  > 

'T  have  no  doubt  that  many  cases  of  neglected  and  adynamic 
remittent,  have  been  classed  and  treated  as  typhoid  fever ;  yet  it 
must  still  be  apparent  to  every  observer,  that  the  circle  of  our 
periodical  fevers  is  diminishing,  while  that  of  typhoid  and  continued 
fever  is  enlarging.  This  may  be  due  to  an  improved  system  of 
agriculture,  to  the  draining  and  cultivation  of  the.  low  creek  and 
swamp  lands.  To  whatever  cause  it  may  be  due,  the  fact  at  any  rate 
is  obvious,  that  as  our  periodic  fevers  have  diminished  in  number 
and  importance,  the  continued  forms  of  fever  have  increased,  and 
in  a  great  measure  replaced  them. 

The  first  cases  of  this  epidemic,  occurred  in  the  family  of  a  gen¬ 
tleman  residing  eight  miles  west  of  Salisbury,  in  the  month  of 
February,  1858,  and  continued  spreading  over  the  adjacent  country 
until  the  month  of  December.  During  that  period  nearly  two  hun¬ 
dred  cases  have  been  treated,  in  this  .county  and  in  that  portion  of 
Davidson  immediately  adjoining. 

The  premonitory  symptoms  were  well  marked.  General  malaise , 
Loss  of  appetite,  disagreeable  taste,  white  and  slightly  coated  tongue, 
disturbed  digestion,  irregularity  of  the  bowels,  sense  of  muscular 
soreness  and  feebleness,  variable  pulse,  dulness  of  intellect,  head¬ 
ache,  and  vertigo,  invariably  preceded  or  accompanied  its  com¬ 
mencement.  In  a  few  days,  the  patient  would  complain  of  great 
chilliness,  or  have  a  decided  rigor,  and  take  to  his  bed,  not  to  leave 
it  again  during  his  illness.  After  several  hours,  reaction  would 
come  on,  the  pulse  would  be  quick  and  feeble  and  continue  so 
throughout  the  attack,  ranging  from  ninety  to  one  hundred  and 
thirty  beats  in  the  minute.  I  saw  some  cases,  in  which  the  pulse 
was  but  little  above  the  normal  standard,  for  weeks  never  exceed¬ 
ing  eighty-eight  at  any  period  of  the  twenty-four  hours.  There 
would  be  two  slight  remissions,  and  two  exacerbations  in  the 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  25 

* 

twenty-four  hours.  This  I  think  is  always  the  case  in  continued 
fever. 

Tenderness  and  gurgling  in  the  right  iliac  region  could  always 
be  found  early  in  the  attack.  Day  after  day  presented  the  same 
role  of  symptoms,  until  about  the  eighth  or  ninth  day,  when  the 
patient  would  complain  of  slight  soreness  of  throat,  and  an  eruption 
on  the  chest  and  abdomen  would  generally  make  its  appearance, 
sparsely  scattered  over  the  surface.  The  time  at  which  the  enteric 
complications  and  cutaneous  eruptions  made  their  appearance  was 
liable  to  very  great  variations,  and  in  some  of  the  cases,  although 
the  other  symptoms  were  well  marked,  the  eruption  could  not  be 
found,  although  carefully  sought  for.  About  the  same  time,  the 
tongue  would  be  coated  in  the  centre  with  the  same  creamy  coat  as 
at  first,  slightly  thickened,  but  the  edges  and  tip  would  be  fiery 
red,  and  the  organ  itself  contracted,  sharp,  and  pointed.  The  abdo¬ 
men  would  now  become  tympanitic  and  diarrhoea  ensue,  or  if  this 
latter  symptom  were  absent,  the  bowels  evinced  unusual  suscepti¬ 
bility  to  the  influence  of  laxative  medicines.  I  remember  produc¬ 
ing  hypercatharsis  in  one  case,  with  six  grains  of  hydrarg.  c.  creta, 
administered  in  two-grain  doses,  at  intervals  of  three  hours. 

As  the  disease  progressed,  in  a  large  majority  of. the  cases  the 
tongue  would  clean  off  suddenly  and  become  red,  slick,  dry  and 
shining,  the  abdomen  become  more  tympanitic,  and  its  tenderness 
increased,  and  the  gurgling  more  distinct.  Delirium  would  now 
set  in,  especially  at  night.  The  patient  muttered  when  asleep,  had 
a  besotted  appearance,  and  exhibited  indifference  to  surrounding 
objects;  subsultus  also  occurred. 

Some  of  the  cases  had  purpura,  bleeding  from  the  gums,  nostrils, 
&c.  One  case  literally  sweat  blood.  In  nearly  all  of  the  cases 
there  was  more  or  less  abdominal  hemorrhage.  One  case  lost,  in  a 
few  hours,  more  than  two  gallons  of  pure  blood  from  the  bowels. 
It  flowed  from  the  rectum,  as  I  have  felt  and  seen  it  flow  from  the 
vagina,  in  uterine  hemorrhage.  He  bled  to  death  in  a  short  time. 

The  time  occupied  in  the  evolution  of  the  different  phases  of  the 
disease  and  its  duration,  varied  in  different  subjects,  some  of  the 
cases  terminating  in  two  weeks;  the  majority  lasting  six,  eight, 
ten,  or  twelve  weeks. 

This  epidemic  I  could  not  but  regard  as  contagious.  Commenc¬ 
ing  on  the  plantation  mentioned,  embracing  a  large  family  of  whites 
and  blacks,  it  spread  in  every  direction. 

Ho  visitors  to  the  house,  who  remained  all  night  and  assisted  in 


26 


REPORT  ON 


nursing  the  sick,  escaped.  The  attending  physician,  Dr.  Luckey, 
ventured  to  remain  one  night,  and  in  eight  or  ten  days  the  premoni¬ 
tory  symptoms  made  their  appearance ;  he  took  to  his  bed  after  a 
decided  chill,  and  was  confined  to  his  room  eight  weeks,  with  well- 
marked  typhoid  fever.  The  family  with  which  he  boarded,  eight 
miles  from  the  first  patients,  all  took  the  disease  from  the  doctor. 
During  'the  harvest,  those  neighbors  who  sent  their  servants  to 
assist  the  gentleman  first  alluded  to  in  saving  his  grain  crops,  soon 
found  that  they  had  unwittingly  introduced  the  pestilence  into 
their  own  families. 

In  a  few  months,  it  had  spread  over  an  area  of  four  or  five  square 
miles,  crept  along  the  creeks,  and  crossed  the  river  into  Davidson 
County.  I  have  myself  been  long  convinced  of  its  contagious  cha¬ 
racter.  This  epidemic  was  typhoid  fever,  and  it  was  unmistakably 
contagious.  Rarely  indeed  do  our  physicians  see  an  isolated  case 
of  typhoid  fever  in  a  family. 

Treatment. — The  treatment  at  first  adopted  was  in  the  first  stage, 
minute  doses  of  mercury,  opium,  and  ipecac,  with  saline  diaphore¬ 
tics  ;  quinine  during  the  remissions,  and  Dover’s  powder  at  night 
to  procure  sleep.  In  the  second  and  last  stages  stimulants,  spts. 
of  turpentine,  blisters,  dry  cups,  acet.  plumbi,  and  opium,  to  restrain 
the  diarrhoea  and  hemorrhages,  with  suitable  nourishment,  &c.  Of 
the  first  eight  cases  so  treated,  four  died. 

In  consultation  with  the  attending  physicians,  we  determined  to 
put  the  rest  of  the  cases  on  the  use  of  ten  grains  of  chlorate  of 
potassa,  every  four  hours ;  small  doses  of  laudanum  to  restrain  the 
bowels,  nourishing,  but  easily  digested  broth,  milk  toddy,  and  when¬ 
ever  hemorrhage  or  any  signs  of  purpura  appeared,  as  large  doses 
of  muriated  tinct.  of  iron  and  ol.  terebinth,  as  the  stomach  would 
tolerate. 

During  the  prevalence  of  the  epidemic,  chlorate  of  potassa  was 
the  main  remedy  in  every  case.  Other  treatment  was  used  only 
as  auxiliary  to  this  medicine.  The  drink  was  a  cold  infusion  of 
slippery-elm  with  ice  in  the  first  stage;  towards  the  decline  of  the  dis¬ 
ease,  a  warm  decoction  of  Virginia  snakeroot  was  substituted  for  it. 

The  exact  ratio  of  mortality  I  am  unable  to  give,  as  I  did  not 
keep  notes  of  the  cases;  but  I  am  sure  it  did  not  exceed  one  in 
forty  after  we  adopted  this  treatment. 

I  have  now  passed  through  the  fourth  epidemic  of  typhoid  fever 
since  my  residence  in  North  Carolina.  I  have  attended  alone,  and 
in  consultation  with  other  physicians,  a  very  large  number  of  cases; 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


27 


and  of  one  thing  I  am  perfectly  convinced,  and  that  is,  that  no  coup 
d'etat  of  professional  skill  or  dexterity  can  ever  suddenly  arrest  the 
progress  of  this  disease.  And  yet  I  doubt  the  propriety  of  consider¬ 
ing  typhoid  fever  a  “self  limiting”  disease.  Indeed,  I  regard  it 
as  a  dangerous  doctrine.  Too  often,  indeed,  the  physician  is  com¬ 
pelled  to  rely  upon  a  very  limited  combination  of  resources,  yet 
his  art  is  of  avail,  in  treating  the  complications  that  are  so  often 
superinduced. 

In  the  “  abortive  plan  I  have  no  confidence,  yet  it  does  not  fol¬ 
low  because  the  disease  cannot  be  thugged  by  heroic  doses  of  qui¬ 
nine,  that  treatment  can  in  nowise  directly  contribute  to  the  arrest 
or  favorable  modification  of  the  malady.” 

I  interpret  rationed  medicine ,  not  to  mean  a  mere  folding  of  the 
arms — an  idle  watching  of  the  disease,  but  the  proper  adaptation  of 
the  proper  remedy  at  the  proper  time.  To  control  symptoms  is  to 
control  results  and  duration. 

While  on  the  one  hand  bad  treatment  may  accelerate  the  progress 
and  fatal  termination  of  typhoid  fever,  on  the  other  hand,  judicious 
treatment  may  often  shorten  its  duration,  and  even  cure  the  patient. 

Dr.  H.  Kelley,  of  Gold  Hill,  Rowan  County,  reports  that  during  the 
fall  and  winter  (1858)  “  we  had  a  good  deal  of  typhoid  fever.  There 
were  two  symptoms  worthy  of  note,  as  occurring  in  this  epidemic, 
viz :  violent  pain  from  the  occiput  to  the  cervical  vertebras,  con¬ 
tinuing  for  several  weeks  in  some  cases,  and  cerebral  symptoms  of 
a  grave  character,  lasting  from  two  or  three  days  to  six  weeks,  pro- 
educing  a  complete  blank  in  the  memory  of  the  patient  for  the  time 
of  their  continuance.” 

“  The  only  deviation  from  the  ordinary  treatment  of  the  disease, 
consisted  in  the  earlier  administration  of  the  ol.  terebinth,  than  has 
been  usual  with  us,  and  in  larger  doses  than  we  had  been  accus¬ 
tomed  to  give  it.  I  gave  it  in  a  number  of  cases  early  in  the  attack, 
and  continued  it  throughout  the  course  of  the  disease,  and  in  not 
a  single  case  so  treated  did  hemorrhage  occur. 

“The  cerebral,  as  well  as  all  the  other  symptoms,  were  much  miti¬ 
gated  by  the  use  of  this  remedy.  I  do  not  think  we  should  wait 
for  the  supervention  of  that  condition  of  the  tongue  described  by 
writers  on  the  disease,  as  indicating  its  use  before  resorting  to  it; 
but  should  commence  its  administration  at  an  early  stage  of  the 
malady. 

“In  the  majority  of  cases  alarming  hemorrhages  occurred,  which 
called  for  large  doses  of  astringents  and  opiates  frequently  admin- 


23 


REPORT  ON 


istered.  After  the  hemorrhage  from  the  bowels  was  arrested,  ob¬ 
stinate  constipation  was  apt  to  supervene,  and  required  the  repeated 
administration  of  castor  oil  to  keep  them  in  a  soluble  condition. 
Convalescence  took  place  slowly.  Notwithstanding  the  severit}^ 
of  this  epidemic,  there  were  comparatively  few  deaths.” 

Dr.  R.  D.  Dickson,  of  Richmond  County,  bordering  on  the  State 
of  South  Carolina,  reports  “  typhoid  fever  as  now  (1858)  and  for 
several  years  past  the  prevailing  form  of  fever  in  that  part  of  the 
State,  replacing  to  a  great  extent  the  remittent  form  of  fever,  which 
was  previously  the  great  endemic  of  the  county. 

tl  My  invariable  rule,  in  the  treatment  of  this  form  of  fe  ver,  is  to 
avoid  all  active  perturbating  measures,  especially  the  administration 
of  strong  purgative  medicines.  Where  such  have  not  been  pre¬ 
viously  given,  I  find  the  disease  for  the  most  part  a  manageable  one. 

“  After  moving  the  bowels  with  a  mild  aperient,  I  rely,  as  a  ge¬ 
neral  remedy,  upon  the  steady  and  persevering  use  of  the  sulph.  of 
quinine  in  moderate  doses  until  a  mild  diaphoresis  is  induced  by 
it.  The  occurrence  of  this  symptom  (diaphoresis)  I  regard  as  a  very 
favorable  indication. 

“  Another  remedy,  of  great  and  indispensable  importance  in  this 
disease,  is  opium  in  some  form.  It  is  with  me  a  leading  indication 
to  procure  quiet  sleep  for  the  patient  every  night.  For  this  pur¬ 
pose,  I  generally  prefer  the  administration  of  pulv.  opii  et  ipecac, 
comp.  The  regular  exhibition  of  suitable  nourishment  with  good 
nursing,  may  be  said  to  constitute  the  remainder  of  the  treatment 
adopted.” 

Dr.  Bedford  Brown,  of  Caswell  County,  reports,  11  that  a  very 
general  epidemic  of  fever  prevailed  in  his  section  of  the  State  in 
the  year  1857.  It  commenced  about  the  first  of  July,  and  ended 
late  in  the  ensuing  November.  The  season  was  characterized  by 
an  unusual  amount  of  moisture,  and  a  temperature  below  the  ave¬ 
rage  of  summer  weather  generally.” 

This  epidemic  comprised  three  different  forms  of  fever,  to  wit, 
genuine  continued  or  typhoid  fever ;  bilious  remittent;  and  a  mixed 
form,  partaking  of  the  character  of  both  to  some  extent. 

The  localities  in  which  typhoid  was  most  prevalent,  were  the 
high,  poor  ridges,  while  the  bottom  lands,  and  their  vicinities,  gave 
rise  to  remittents.  The  mixed  form  was  not  restricted  to  either 
locality.  In  the  selection  of  locality,  there  was  manifestly  an 
existing  antagonism  between  typhoid  and  remittent  fever. 

Neither  the  origin  of  typhoid  fever,  nor  its  extension  here  could 


THE  EPIDEMICS  OF  NOETH  CAROLINA. 


29 


be  accounted  for  on  the  principle  of  contagion.  Frequently  a 
number  of  cases  would  appear  simultaneously  in  the  same  family, 
without  any  previous  communication  with  cases  of  a  similar  cha¬ 
racter.  We  could  not  do  otherwise  than  attribute  it  to  miasmatic 
causes,  modified  either  by  local  or  constitutional  influences. 

“The  disease  was  unusually  protracted  in  its  duration  and  of  a 
low  character.  The  progress  of  the  epidemic  was  in  a  westerly 
direction,  and  by  far  the  largest  number  of  cases  occurred  among 
our  negro  population.  It  not  unfrequently  happened,  that  the 
entire  black  portion  or  a  family  would  be  attacked,  while  the 
white  members  would  remain  exempt  from  the  disease,  contrary  to 
our  preconceived  opinions.  The  constitution  of  the  negro  also 
resisted  the  disease  better  than  that  of  the  whites,  the  mortality 
being  greater  among  whites  than  blacks  in  proportion  to  the  num¬ 
ber  attacked. 

“  The  cases  which  came  under  my  observation  were  seldom  or 
never  on  the  extremes  of  age,  and  by  far  the  largest  portion  were 
males. 

“During  the  progress  of  the  disease,  there  occurred  but  few  local 
complications.  Parotitis  occurred  in  several  instances  without 
materially  influencing  the  progress  of  the  case.  Hemorrhage  to  a 
fatal  extent  occurred  only  occasionally.  Sloughing  of  exposed 
parts  occurred  very  frequently,  and  what  is  remarkable,  took  place 
about  the  period  when  recovery  began. 

“  In  regard  to  treatment ,  my  chief  reliance  was  placed  on  the  free 
administration  of  diffusible  stimulants,  such  as  the  different  forms 
of  alcoholic  liquors,  carb.  ammonias,  &c.,  and  the  plentiful  supply 
of  nourishment,  judiciously  selected  with  a  view  to  its  digestibility 
and  the  amount  of  concentrated  nutriment  it  contained,  and  the 
exhibition  of  such  remedies,  as  were  calculated  to  prevent  the  ex¬ 
cessive  drain  of  material  from  the  system,  through  the  intestinal 
canal. 

“So  fully  satisfied  am  I  of  the  superiority  of  this  plan  of  treat¬ 
ment,  that  I  have  repeatedly  asserted,  among  medical  men  and 
others,  that  any  given  number  of  cases  of  continued  fever,  without 
regard  to  existing  variations  or  complications,  treated  by  a  plenti¬ 
ful  exhibition  of  stimulants  and  nourishment,  with  proper  atten¬ 
tion  to  the  usual  diarrhoea,  would  afford  more  successful  results, 
than  all  other  modes  of  treatment  combined. 

“  Intercurrent  inflammations  are  rarely  to  be  apprehended  in 
typhoid  fever.  There  is  in  this  disease  an  over-excitement,  with  co- 
3 


30 


REPORT  ON 


existing  loss  of  vital  power  which  produces  a  strong  predisposition 
to  local  congestions  with  a  degree  of  sub-inflammatory  action.  To 
obviate  this  condition  of  things,  stimulants  have  a  peculiar  power, 
by  invigorating  the  vital  forces. 

“I  have  frequently  pushed  this  treatment  to  an  almost  incredible 
extent,  and  continued  it  for  days  and  weeks,  when  fever  and  de¬ 
lirium  were  constantly  present,  with  ultimate  good  results. 

“  In  those  cases  in  which  the  circulation  was  too  much  excited, 
I  have  frequently  used  the  veratrum  viride)  and  can  testify  to  its 
value. 

“When  the  pulse,  as  it  did  in  some  cases,  became  so  rapid  and 
feeble  as  to  assume  the  character  of  a  ‘  fluttering  pulse,’  this  drug 
would  reduce  it  to  a  normal  state.  The  oil  of  turpentine ,  so  highly 
recommended  by  Prof.  Wood,  was  frequently  used,  but  never  with 
satisfactory  results  in  typhoid  fever.  The  nitrate  of  silver  and 
chlorate  of  potash,  have  in  my  experience  answered  a  better  pur¬ 
pose. 

“  That  form  of  fever  which  I  have  termed  mixed ,  presented  many 
of  the  leading  characteristics  of  typhoid,  yet  differed  essentially 
in  some  particulars.  This  difference  consisted  chiefly  in  the  more 
rapid  march  of  the  disease,  and  in  a  regular  diurnal  remission, 
febrile  exacerbations  and  perspiration.  This  form  of  fever  yielded 
very  readily  to  the  sulphate  of  quinia,  whereas  this  medicine  ex¬ 
erted  no  control  whatever  over  the  progress  of  genuine  typhoid 
cases. 

“  About  the  middle  of  November,  the  epidemic  of  typhoid  fever 
ceased,  and  pneumonia  of  a  decidedly  typhoid  type  made  its  ap¬ 
pearance. 

“The  spring  months  of  1858  were  comparatively  healthy,  but 
about  the  beginning  of  summer  whooping-cough  set  in,  and  rapidly 
spread  over  the  country.  It  proved  unusually  fatal  to  young 
infants;  the  fatal  complications  being  congestion  of  the  brain, 
pneumonia,  and  infantile  remittent  fever.  To  this  last  complication 
I  will  make  more  special  allusion  than  to  the  others. 

“Not  unfrequently,  all  of  the  children  from  a  few  months  to 
twelve  years  old,  in  a  family  suffering  from  whooping-cough,  would 
be  attacked  also  with  this  form  of  fever.  The  approach  of  the  dis¬ 
ease  was  generally  gradual.  At  first  there  was  constipation ;  as 
the  disease  advanced  diarrhoea  supervened.  Tympanitis  was  never 
absent,  indigestion  and  lientery  were  generally  present,  and  pro¬ 
duced  marked  prostration  and  emaciation.  The  pulse  was  invaria- 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


31 


bly  rapid.  There  were  regular  daily  remissions  in  the  morning, 
with  febrile  exacerbations  at  evening,  and  copious  perspirations  at 
night.  This  free  perspiration  afforded  no  protection  against  a  re¬ 
currence  of  the  same  symptoms.  The  secretions  were  always  vi¬ 
tiated  and  depraved.  In  all  seven  cases  nervous  symptoms  were 
developed ;  the  urine  was  scanty,  and  loaded  with  solid  material. 

u  In  regard  to  the  treatment  of  this  disease,  I  wish  to  speak  par¬ 
ticularly  of  the  inestimable  value  of  the  oil  of  turpentine,  and 
sulphate  of  quinia.  The  first  would,  by  acting  on  the  universal 
mucous  surface,  relieve  the  cough,  the  lienteric  form  of  diarrhoea, 
and  the  tympanitis,  and  finally  produce  a  copious  flow  of  limpid 
urine.  In  some  instances  the  quantity  of  urine  discharged  was  so 
great,  that  I  could  compare  it,  with  truth,  to  the  amount  discharged 
in  diabetes  mellitus.  This  was  usually  an  index  of  a  change  in 
the  patient’s  condition,  and  of  a  subsidence  of  the  attack.  The 
quinia  produced  most  happy  effects,  by  relieving  the  paroxysms  of 
fever.” 

Typhoid  fever  is  reported  as  prevailing  to  some  extent  in  Hyde 
County,  in  1859,  by  Dr.  Cramer,  and  in  Perquimans  County,  by 
Dr.  Coxe,  and  in  Franklin  County,  by  Dr.  Lankford. 

The  two  first  mentioned  are  extreme  eastern  counties  bordering 
on  the  sea,  and  in  an  alluvial  region  but  little  elevated  above  the 
level  of  the  ocean  ;  the  last  in  the  middle  region  of  the  State. 

On  the  authority  of  Dr.  Hackett,  of  Wilkesboro’,  I  am  enabled 
to  report  the  prevalence  of  typhoid  fever  in  the  county  of  Wilkes, 
in  the  most  elevated  mountain  region  of  the  State.  He  informs 
me  that  he  has  seen  it  prevailing  on  the  very*  summit  of  the  Blue 
Kidge,  and  under  circumstances  almost  conclusively  establishing 
its  contagious  character  and  marked  by  decided  indications  of  pu- 
trescency  of  the  fluids. 

It  would  thus  seem  to  be  entirely  independent  of  ordinary  at¬ 
mospheric  conditions ;  prevailing  equally  and  with  equal  intensity 
in  the  rare  atmosphere  of  the  mountains,  and  the  denser  air  of  the 
sea  coast.  \ 

The  foregoing  facts  and  observations  would  seem  to  have  esta¬ 
blished  the  point,  that  by  a  gradual  and  steady  progress,  typhoid 
fever  has  come  to  occupy  the  entire  State,  and  that  like  the  strictly 
zymotic  diseases,  it  is  irrespective  of  climate,  of  season,  or  of  any 
known  local  conditions. 

Like  them,  too,  there  would  seem  to  be  good  grounds  for  con¬ 
cluding  that  it  is,  under  certain  conditions,  a  contagious  malady. 


32 


REPORT  ON 


There  can  be  no  doubt  but  that  it  is  the  same  disease  which  has 
been  so  carefully  studied  and  investigated  in  this  country,  by  Drs. 
Gerhard,  Bartlett,  Flint,  and  others,  and  by  Bouis,  Jenner,  Budd, 
Stokes,  and  Tweedie  in  Europe. 

Into  the  obscure  question  of  its  etiology  and  pathology,  it  would 
be  out  of  place  to  enter  in  such  a  paper  as  this.  The  careful  obser¬ 
vations  and  well  sifted  facts  of  that  industrious  and  systematic 
observer,  Dr.  Jenner,  have  only  resulted  in  establishing  its  non¬ 
identity  with  typhus  fever,  to  which  in  many  of  its  features  it  bears 
so  strong  a  resemblance. 

The  investigations  of  Dr.  Budd  have  led  him  to  infer  that  the 
intestinal  lesion,  which  constitutes  so  uniform  a  feature  in  this  dis¬ 
ease,  is  a  sort  of  introverted  exanthem,  the  specific  eruption  of  a 
contagious  disease,  and  the  intestinal  discharges,  the  materies  morbi 
by  which  it  is  propagated.  Some  of  our  American  physicians  have, 
I  think,  claimed  to  be  able  to  detect  what  they  have  denominated 
the  typhoid  element  in  the  intestinal  discharges  and  to  base  their 
differential  diagnosis  of  the  disease  on  this  symptom.  Such  views 
have,  I  think,  been  announced  by  Dr.  McCaw,  of  Kichmond,  in  the 
Virginia  Medical  Journal . 

If,  as  Dr.  Budd  thinks,  the  intestinal  discharges  are  the  media  by 
which  typhoid  fever  is  propagated,  the  conclusion  of  Dr.  Jenner 
that  it  is  not  the  product  of  idio-miasma,  is  subverted  by  the  obser¬ 
vations  of  Dr.  Budd,  who,  in  tracing  its  contagiousness  to  a  special 
excretion,  has  settled  this  point  with  regard  to  typhoid,  quite  as 
conclusively  as  has  yet  been  done  with  regard  to  typhus ,  the  con¬ 
tagiousness  of  which  has  not  been  proved  to  depend  upon  any 
particular  excretion  of  the  diseased  organism. 

When  typhoid  fever  first  began  to  prevail  in  the  eastern  section 
of  this  State,  cases  exhibiting  the  blending  or  commingling  of  this 
type  of  fever  with  remittent  fever,  were  by  no  means  uncommon, 
and  in  these  cases  it  was  necessary  to  keep  in  view  its  hybrid  cha¬ 
racter,  in  the  treatment;  for  such  cases  could  not  be  well  managed 
without  the  use  of  quipine.  .. 

Treatment. — As  typhoid  fever,  like  other  diseases  which  run  a 
definite  course,  has  for  the  most  part  a  tendency  to  terminate  in  a 
restoration  to  health,  it  is  somewhat  difficult  to  determine  the  value 
of  remedies  in  its  treatment. 

Though,  as  a  general  rule,  the  nimia  diligentia  medici  is  to  be 
avoided,  we  can  still  prescribe  with  advantage  for  such  symptoms 
as  appear  to  require  attention,  and  if  many  cases  are  injured  by 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  33 

injudicious  hypermedication,  it  is  equally  certain  that  many  cases 
would  prove  fatal  from  the  neglect  of  a  proper  use  of  remedies  at 
the  proper  juncture. 

Without  attempting  to  enter  in  extenso  into  the  treatment,  I  will 
content  myself  with  referring  to  such  remedies  and  modes  of  treat¬ 
ment  as  have  recently  been  found  useful,  or  which  may  possess  the 
interest  of  novelty. 

The  chlorate  of  potash,  it  will  be  observed,  is  highly  recommended 
by  Dr.  Whitehead,  as  having  been  of  notable  utility  in  the  treat¬ 
ment  of  an  epidemic  of  this  disease,  which  prevailed  in  his  neigh¬ 
borhood,  and  which  had  been  marked  by  great  fatality  before  this 
medicine  had  been  resorted  to.  It  has  since  then  become  a  popular 
prescription  throughout  the  State,  and  I  believe  it  maintains  its 
character  with  the  profession  generally. 

The  oil  of  turpentine,  too,  would  seem  to  maintain  the  reputation 
which  it  has  acquired  in  the  treatment  of  the  advanced  stages  of 
the  disease.  Dr.  Kelly,  of  Rowan,  tells  us  that,  in  treating  the 
disease  as  it  prevailed  in  his  neighborhood,  it  was  found  useful  to 
resort  to  it  at  an  early  stage  of  the  disease  and  to  administer  it  in 
larger  doses  than  had  been  usual.  He  is  of  opinion  that  so  adminis¬ 
tered,  it  exerted  a  prophylactic  power  against  intestinal  hemor¬ 
rhage. 

Bloodletting. — That  bloodletting  should  be  mentioned  at  all  in 
connection  with  typhoid  fever  as  a  remedy,  will  strike  many  with 
unmingled  surprise. 

,  We  must  not,  however,  suffer  our  preconceived  notions  or  our 
hypothetical  views  of  the  disease  and  its  proper  treatment,  to  blind 
us  as  to  the  existence  of  facts  which  do  not  accord  with  these  views. 
Dr.  Owen  Hadley,  of  Richmond  County,  writes  me,  that  for  the  last 
thirteen  years,  he  has  been  in  the  habit  of  using  the  lancet  in  the 
treatment  of  the  typhoid  fever  of  his  section  of  the  State. 

Finding  the  treatment  ordinarily  recommended  by  systematic 
and  practical  writers  on  the  disease,  utterly  unavailing  and  seem¬ 
ingly  worse  than  useless,  he  was  led  to  adopt  bloodletting  as 
apparently  indicated  in  all  cases  in  which  there  were  evidences  of 
cerebral  excitement,  and  finding  that  he  was  much  more  successful 
in  the  management  of  such  cases  than  he  had  been  before  resorting 
to  bleeding,  he  was  induced  to  extend  its  use  to  other  cases,  and 
particularly  to  the  hemorrhagic  forms  of  the  disease.  His  experi¬ 
ence  (he  says)  has  satisfied  him  that  hemorrhage  from  the  bowels 


EE POET  ON 


34 

particularly,  is  a  very  rare  occurrence  when  bleeding  has  been 
practised  early  in  the  case. 

However  opposed  to  the  commonly  received  views  of  the  profes¬ 
sion  and  the  practice  founded  on  these  views,  the  use  of  the  lancet 
in  typhoid  fever  may  seem,  the  experience  of  a  calm  discriminating 
observer  and  conscientious  practitioner  cannot  properly  be  ignored. 

It  may  be  that  the  type  of  the  disease  which  prevails  in  Dr. 
Hadley’s  section  of  the  State  is  essentially  different  from  the  com¬ 
monly  prevailing  form  of  the  disease ;  or  it  may  be  that  we  have 
allowed  our  hypothetical  views  of  the  nature  and  pathology  of 
the  disease  to  influence  us  too  strongly  to  the  prejudice  of  blood¬ 
letting.  Dr.  Hadley  does  not  contend  that  the  duration  of  the 
disease  is  at  all  shortened  by  bleeding,  but  he  insists  upon  it  that 
the  severer  symptoms  are  mitigated  and  the  cases  conducted  to  a 
satisfactory  termination  in  much  larger  proportion  than  when  this 
remedy  has  been  omitted.  So  essential  does  he  consider  bloodlet¬ 
ting  in  the  earlier  stages  of  the  disease,  that  he  does  not  hesitate  to 
pronounce  it  the  remedy  for  which,  in  his  experience,  there  is  no 
substitute.  Where  it  has  not  been  practised,  he  states  that,  in  a 
large  number  of  cases,  intestinal  hemorrhage  will  come  on  in  two 
or  three  weeks,  and  three-fourths  of  the  cases  terminate  fatallj7. 

Veratrum  viride. — This  agent  does  not  appear  to  have  been  ex¬ 
tensively  used  in  the  treatment  of  typhoid  fever  in  this  State ;  at 
least  all  the  reports  which  I  have  received  are  silent  upon  this 
point.  Most  of  the  cases  of  typhoid  fever,  which  have  fallen  under 

mv  notice  since  the  introduction  of  the  verat.  virid.  into  use  as  a 

•/ 

remedy  for  it,  have  not  been  characterized  by  any  very  remarkable 
frequency  of  pulse,  and  hence  the  use  of  this  drug  has  not  apparently 
been  indicated. 

Quinine. — In  a  disease  of  such  protracted  duration  as  typhoid 
fever,  the  blood  and  tissues  become  impoverished  in  consequence 
of  the  loss  of  the  proper  equilibrium,  which  should  exist  in  the 
process  of  repair  and  waste,  and  hence  the  secretions  must  become 
abnormal  and  vitiated. 

Whether  it  be  true,  as  Dr.  Casselberry  maintains,1  that  quinine 
supplies  food  for  the  automatic  nervous  system,  which  presides  over 
the  function  of  nutrition,  or  not,  its  utility  in  the  treatment  of  typhoid 
fever  can  hardly  be  called  in  question.  This  invaluable  medicine 
seems  to  have  the  power  of  at  the  same  time  sustaining  the  tone  of 


1  Amer.  Jour.  Med.  Sciences,  April,  1858. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


35 


the  nervous  system,  while  it  calms  vascular  excitement,  and  though 
it  is  not  entitled  to  the  character  of  a  specific,  it  can  rarely  be  dis¬ 
pensed  with  in  the  treatment  of  typhoid  fever  at  some  stage  of  its 
progress. 

Cold  water. — Cold  water  must  be  regarded  as  a  remedy  of  great 
value  in  the  treatment  of  typhoid  fever.  It  not  only  adds  greatly 
to  the  comfort  of  the  patient,  but  exerts  a  positive  remedial  agency 
in  abating  the  febrile  excitement.  As  an  irregular  distribution  of 
heat  is  a  notable  feature  in  this  disease,  a  very  obvious  indication 
seems  to  be  to  endeavor  to  equalize  it  as  much  as  possible,  and  I 
know  of  no  remedy  equal  to  the  steady  use  of  cold  water,  in  re¬ 
ducing  morbidly  increased  temperature.  When  the  head  is  too 
hot,  a  napkin  wet  with  cold  water  should  be  wrapped  around  the 
head.  When  there  is  inordinate  heat  of  the  abdomen  or  thorax, 
similar  applications  should  be  made  to  them  respectively.  In  the 
latter  stages  of  the  disease,  when  there  is  evident  bronchial  compli¬ 
cation,  the  application  of  cold  water  to  the  chest  would  not  pro¬ 
bably  be  so  safe,  and  under  such  circumstances  sinapisms  and 
epispastics  are  to  be  preferred. 

As  water  is  the  universal  solvent  and  depurative,  it  cannot  be 
dispensed  with,  in  the  early  stages  of  the  disease  especially.  Indeed, 
it  is  indispensable  in  all  its  stages.  Being  the  necessary  vehicle 
for  the  introduction  of  the  new  material  to  supply  the  waste  of  the 
tissues,  and  for  the  removal  of  the  effete  material  also,  we  are 
constrained  to  regard  it  as  the  great  febrifuge  which  nature  prompts 
us  to  adopt,  and  without  which  all  other  remedies  would  be  of 
little  avail. 

SCARLET  FEVER. 

Scarlatina  may  now  be  said  to  be  one  of  our  regular  epidemics. 
Yery  few  years  pass,  without  the  occurrence  of  sporadic  cases  of 
this  disease,  and  every  three  or  four  years  we  have  it  prevailing  as 
an  epidemic. 

No  section. of  the  State  can  now  be  said  to  enjoy  an  exemption 
from  this  terrible  pestilence.  Like  typhoid  fever,  it  was  for  many 
years  regarded  by  us  of  the  eastern  section  of  the  State,  as  an  up- 
country  disease,  and  there  are  now  living  medical  men  who  prac¬ 
tised  their  profession  in  the  town  of  Wilmington  for  twenty-five 
years  without  ever  having  encountered  a  case  of  scarlet  fever  during 
the  whole  of  that  period.  Nor  are  there  any  historical  or  tradition¬ 
ary  accounts  of  its  ever  having  previously  prevailed  here. 


36 


REPORT  ON 


About  the  year  1835,  it  effected  a  lodgement  in  this  place  and 
lias  never  since  entirely  relinquished  its  hold. 

Within  the  last  five  years,  we  have  had  two  epidemics  of 
fever  in  Wilmington,  of  considerable  severity.  In  both  epidemics 
the  great  majority  of  cases  were  of  the  milder  type,  but  cases  pre¬ 
senting  the  disease  in  its  most  malignant  form  were  by  no  means 
rare. 

Though  more  apt  to  prevail  in  winter  and  spring,  I  have  known 
one  epidemic  to  extend  into  the  summer  months  and  reach  its 
culmination  in  June.  It  would  thus  seem  to  be  quite  as  irrespec¬ 
tive  of  season,  as  its  congeners  of  the  exanthematous  class,  rubeola 
and  variola. 

While  it  is  one  of  the  special  diseases  of  childhood,  adults  are 
not  exempt  from  it,  and  very  young  children,  as  far  as  my  observa¬ 
tion  extends,  are  equally  liable  to  it  as  those  of  a  more  advanced 
age. 

The  number  of  cases  which  occurred  in  the  last  outbreak  of  scar¬ 
latina  as  an  epidemic  in  December  and  January,  1858,  in  Wilming¬ 
ton,  was  not  very  great ;  but  the  epidemic  exhibited  the  usual 
variety  of  types,  from  the  mildest  form  of  scarlatina  simplex  to  the 
most  malignant  anginose  variet}7. 

The  anginose  affection  very  rarely  presented  the  gangrenous  form. 
There  was  ordinarily  swelling  and  erythematous  redness  of  the  soft 
palate,  tonsils  and  uvula,  with  patches  of  exudation.  Difficulty  of 
deglutition,  swelling  of  the  submaxillary  and  cervical  glands,  were 
commonly  present.  A  yellowish  pasty  coating  covered  the  tongue, 
its  edges  and  papillae  being  fiery  red.  A  profuse  secretion  of 
viscid  mucus  from  the  fauces,  and  a  copious  and  acrid  defluxion 
from  the  nostrils  occurred  in  most  forms  of  the  disease.  The  exu¬ 
dative  inflammation  sometimes  extended  into  the  larynx,  the  patient 
dying  with  all  the  indications  of  pseudo-membranous  croup.  In 
a  few  cases  the  parotid  gland  on  one  side  was  swollen,  and  this  soon 
came  to  be  regarded  as  a  very  unfavorable  symptom,  for  recovery 
was  very  rare  after  suppuration  of  this  gland  had  taken  place. 

In  a  few  cases,  the  disease  was  fatal  in  its  incipient  stages,  the 
highly  poisoned  blood  seeming  to  give  rise  to  a  rapid  form  of  ce¬ 
rebral  or  cerebro-spinal  meningitis  with  convulsions;  or  delirium 
soon  succeeded  by  coma  would  come  oh,  and  the  patient  succumb 
without  any  obvious  effort  on  the  part  of  the  system  at  reaction. 

Although  the  general  features  of  the  disease  were  for  the  most 
part  strikingly  alike  in  all  the  cases,  a  case  would  occasionally 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


37 


occur  with  some  peculiar  features  superadded  to  the  common  role 
of  symptoms,  characteristic  of  the  malady. 

Thus,  in  one  case  a  tendency  to  sloughing  exhibited  itself,  in  a 
well  defined  spot  about  the  size  of  a  dollar  on  the  inside  of  one 
thigh,  and  after  the  slough  had  separated  and  some  expectations 
were  being  entertained  of  the  recovery  of  the  patient,  a  gangre¬ 
nous  spot  made  its  appearance  on  the  instep  of  the  same  side,  and 
the  case  terminated  fatally,  with  the  supervention  of  anginose 
symptoms  on  the  twelfth  day  of  the  disease. 

Dr.  McKee,  of  Raleigh,  reports  in  1855,  a  form  of  scarlatina  and 
measles  combined,  as  prevailing  in  that  city  and  neighborhood. 
His  report  states  that  so  hybrid  were  these  cases  in  their  appear¬ 
ance,  that  in  some  instances  it  was  difficult  to  discriminate  between 
the  two,  or  to  determine  which  morbid  element  had  the  prepon¬ 
derance. 

In  the  spring  and  early  part  of  the  summer  of  1854,  a  similar 
form  of  the  hybrid  disease  was  of  occasional  occurrence  in  Wil¬ 
mington.  Measles  was  the  predominant  epidemic  of  the  season,  and 
some  of  the  cases  were  of  an  unusually  severe  character. 

In  a  small  number  of  instances,  the  disease  assumed  the  con¬ 
gestive  type.  The  virulence  or  the  amount  of  the  poison  seemed 
so  to  prostrate  the  vital  forces,  as  to  preclude  any  effort  at  reaction. 
Death  seemed  in  such  cases  to  be  the  result  of  an  apparent  paralysis 
of  the  peripheral  branches  of  the  ganglionic  system  of  nerves,  and 
of  the  capillary  vascular  system  dependent  upon  them,  and  a  gen¬ 
eral  coldness  and  lividity  of  the  extremities,  and  of  the  entire  super¬ 
ficies  of  the  body  rapidly  ushered  in  the  fatal  termination;  the 
nutritive  calorific  and  blood-depurative  functions  being  apparently 
simultaneously  arrested. 

A  large  number  of  the  cases  in  all  of  our  epidemics  were  followed 
by  the  ordinary  sequelae  of  the  disease.  Anasarca  and  ascites  were 
not  uncommon,  attended  with  albuminuria  and  in  some  cases  with 
haematuria,  indicative  of  great  vascular  congestion  of  the  kidneys, 
and  requiring  local  depletion  and  the  use  of  the  milder  diuretics 
in  its  treatment.  Deafness,  and  occasionally  otorrhoea  occurred  as 
sequelae ;  suppuration  of  the  parotid  and  submaxillary  glands  now 
and  then  occurred,  with  profuse  suppurative  discharge. 

Uremic  Eclampsia. — This  is  a  very  rare  sequel  of  the  disease,  and 
a  very  formidable  one.  It  is  more  apt  to  follow  mild  than  severe 
cases  of  the  disease.  In  cases  in  which  the  cutaneous  efflorescence 
is  slight,  the  blood  would  seem  to  be  less  thoroughly  depurated  of 


38 


REPORT.  OX 


its  poisonous  element,  and  severe  sequelae  are  more  apt  to  result. 
These  cases  are  marked  by  puffiness,  or  cedematous  intumescence 
of  the  face,  and  by  remarkable  drowsiness,  almost  amounting  to 
stupor.  The  urine  is  scanty  in  quantity,  highly  albuminous,  turbid, 
depositing  in  some  cases  a  sooty  material,  having  the  appearance  of 
broken-down  blood-globules,  or  there  may  be  hsematuria,  clear  florid 
blood  passing  off  with  the  urine. 

If  this  condition  of  the  kidneys  is  not  soon  relieved  by  appro¬ 
priate  treatment  severe  convulsions  follow,  resembling  in  every 
particular  the  convulsions  of  puerperal  eclampsia. 

Dr.  Cox,  of  Perquimans  County,  reports  the  prevalence  of 
scarlet  fever  in  his  neighborhood,  in  the  months  of  January  and 
February,  1858,  in  a  mild  form  at  first,  but  about  the  first  of  March 
assuming  a  graver  type,  and  diffusing  itself  more  extensively. 

In  some  families  it  assumed  the  malignant  form,  and  carried  off 
its  victims  in  a  few  hours  from  the  overwhelming  influence  of  the 
poison  on  the  nervous  system,  which  completely  prostrated  them 
in  the  first  stages  of  the  disease.  In  other  families,  the  disease 
assumed  a  mild  form,  and  the  patients  required  but  little  treatment. 
^Whichever  type  of  the  disease  made  its  appearance  in  a  family, 
that  type  was  apt  to  run  though  the  family,  whether  it  was  the 
simple,  the  anginose,  or  the  malignant  type. 

Treatment. — As  regards  the  treatment  of  scarlet  fever,  I  have  but 
little  to  say.  The  milder  forms  of  the  disease  got  well  with  little 
or  no  treatment,  the  severer  type  was  not  amenable  to  any  treatment 
I  could  devise.  Almost  all  the  remedies  which  have  been  recom¬ 
mended  in  systematic  treatises  and  in  the  periodicals  have  in  turn 
been  tried,  and  with  negative  results  in  all  cases.  In  the  anginose 
variety,  bleeding,  either  general  or  local,  has  not  been  practised  of 
late  years,  as  they  have  been  found  not  only  useless,  but  hurtful. 

This  was  not  the  case  when  the  disease  first  invaded  this  locality 
(Wilmington)  in  1835.  Bleeding  was  then  found  to  be  decidedly 
useful  if  practised  early,  and  evidently  mitigated  the  severity  of  the 
subsequent  fever. 

Of  late  years,  a  tonic  and  supporting  treatment  has  generally 
been  practised,  and  diffusible  stimuli  resorted  to  at  all  stages  of 
the  disease. 

Emetics  were  useful  in  dislodging  the  viscid  mucus  from  the 
fauces,  and  were  generally  resorted  to  in  all  cases  complicated  with 
bronchitis. 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  39 

Sulph.  quinine  with  infusion  of  serpentaria  and  capsicum  was 
occasionally  used  with  seeming  benefit. 

Nitro-muriatic  and  acetic  acid  and  the  chlorate  of  potass  were 
also  freely  used. 

But,  upon  the  whole,  the  results  of  treatment  were  by  no  means 
satisfactory.  If  the  dose  of  the  poison  received  into  the  system 
happened  to  be  greater  than  could  be  thrown  off  by  the  skin  and 
mucous  surfaces,  it  was  almost  as  certainly  fatal  as  is  the  virus  of 
the  crotalus  or  that  of  the  cobra  di  capello. 

CEREBRO-SPINAL  MENINGITIS. 

Dr.  W.  B.  Sharpe,  of  Davie  County,  reports  that  this  epidemic 
appeared  in  his  neighborhood  in  March,  1856,  the  spring  succeeding 
the  first  of  the  two  cold  winters,  the  severity  of  which  has  distin¬ 
guished  them  from  any  others  for  the  last  fifteen  years. 

This  epidemic  to  me  (Dr.  Sharpe)  is  striking.  First,  from  its 
novelty;  secondly,  from  its  fatal  tendency;  and  thirdly,  from  the 
rapidity  with  which  it  runs  its  course.  The  same  disease  prevailed 
in  1857,  but  was  much  milder  and  more  manageable  than  it  was  on 
its  first  appearance.  According  to  my  observation,  the  age  most 
liable  to  be  attacked  was  from  fifteen  to  twenty-two  years  old  ; 
there  were  many  younger,  but  not  many  older  persons  attacked. 
Children  from  two  years  old  and  upwards  were  not  exempt. 

In  some  instances  the  attack  was  sudden,  the  patient  at  once 
complaining  of  violent  pain  in  the  head,  and  in  a  short  time  would 
in  most  cases  be  insensible,  and  in  a  few  hours  fall  into  convulsions, 
death  following  in  many  cases  in  from  six  to  twelve  hours.  In 
other  cases,  especially  among  those  from  fifteen  to  twenty  years 
old,  the  patients  would  complain  of  slight  pain  in  the  head,  with 
some  indisposition,  for  three  or  four  days ;  and  then  would  sud¬ 
denly  complain  of  severe  pain,  and  fall  in  attempting  to  walk,  and 
in  a  short  time  become  insensible,  either  talking  incoherently,  or 
lying  in  stupor.  In  this  condition  he  might  remain  twelve  or 
eighteen  hours ;  but  in  many  cases  convulsions  ensued  earlier  than 
this,  and  even  death.  If  called  early,  on  approaching  the  patient 
he  would  probably  be  found  with  flushed  cheeks,  full  and  bounding 
pulse,  with  one  eye  looking  a  little  watery  and  its  conjunctiva 
slightly  injected  and  inflamed.  In  most  cases  the  patient  would 
describe  the  pain  as  being  confined  to  one  side  of  the  head,  in  one 
temple,  or  over  one  eye. 


40 


REPORT  ON 


If  the  case  is  about  to  prove  successful,  the  patient  may  com¬ 
plain  of  violent  pain  in  one  ear,  or  the  eye  and  side  of  the  face  will 
become  swollen.  Either  of  these  occurrences  (and  especially  the 
latter),  I  hail  as  a  favorable  omen,  as  it  is  evident  that  the  brain 
and  its  membranes  are  being  relieved,  and  that  the  disease  is  be¬ 
coming  external.  The  swelling  of  the  face  or  the  pain  in  the  ear 
soon  subsides,  and  the  patient  is  convalescent. 

The  swelling  of  the  face  (which  is  erysipelatous  in  its  character), 
is  one  of  the  best  evidences  that  the  disease  of  the  brain  is  of  a 
like  nature.  After  convulsions  come  on,  there  is  no  flush  of  the 
cheek,  and  the  temperature  of  the  surface  is  but  little  if  at  all  ele¬ 
vated  ;  on  the  contrary  it  is  often  cool  and  pale,  while  the  pulse  is 
but  little  affected,  except  as  to  frequency.  As  evidence  of  the 
rapidly  fatal  nature  of  the  disease,  I  may  state  that  I  have  known 
a  young  and  apparently  healthy  lady,  take  a  ride  in  the  morning, 
return,  and  before  twelve  o’clock  complain  of  some  pain  in  the  head, 
in  a  few  hours  become  insensible,  and  before  midnight  a  corpse.  I 
have  also  been  called  to  a  young  man,  who  had  complained  of  some 
pain  in  the  head  for  three  or  four  days,  and  seemed  indisposed  to 
move  about  or  take  exercise,  or  to  pay  attention  to  what  was  pass¬ 
ing  about  him,  yet  give  no  uneasiness  to  his  friends  or  family,  until, 
on  the  third  or  fourth  day,  he  suddenly  complained  of  violent  pain 
in  the  head,  fell  helpless  and  insensible  to  the  floor,  and  whom  I 
found  on  my  arrival,  with  one  convulsion  after  another,  continuing 
until  death. 

This  disease  struck  terror  to  the  neighborhood  when  it  first  ap¬ 
peared.  I  was  myself  shocked  and  confused  with  the  first  few 
cases,  which  appeared  as  sudden  and  overwhelming  as  an  avalanche. 
I  have  seen  this  disease  commence  with  the  father  of  a  family,  and 
in  four  days  attack  six  children,  one  after  another  (leaving  only 
the  mother  and  a  sucking  child  untouched),  each  appearing  to  be 
in  perfect  health  an  hour  before  the  attack. 

I  have  not  been  able  to  learn  that  this  epidemic  appeared  in  any 
part  of  the  country  prior  to  its  breaking  out  in  this  county.  The 
northern  part  of  this  county,  which  did  not  suffer  from  this  epide¬ 
mic  in  the  spring  of  its  first  appearance  here,  was  attacked  in  the 
early  part  of  the  winter  following.  In  the  county  north  of  this 
and  immediately  adjoining  the  latter  neighborhood,  in  the  following 
spring,  it  proved  quite  fatal.  We  had  a  recurrence  of  the  epidemic 
in  the  spring  of  1857 ;  but  for  the  most  part  only  in  those  neigh¬ 
borhoods  which  were  in  a  measure  exempt  during  the  spring  of 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


41 


its  first  appearance.  It  was  of  much  milder  type,  showing  itself 
in  many  cases  of  swelling  on  one  side  of  the  face  at  the  onset  of 
the  disease. 

This  disease  differs  from  ordinary  inflammation  of  the  brain  and 
its  membranes' — first,  in  that  it  prevailed  as  an  epidemic  ;  secondly, 
that  only  one  side  of  the  head  was  in  most  of  the  cases  complained 
of ;  thirdly,  that  there  was  swelling  on  one  side  of  the  face,  in  very 
many  cases  as  the  disease  was  giving  way,  and  in  some  cases  from 
the  onset,  and  especially  so  as  the  epidemic  was  subsiding ;  and 
fourthly,  that  the  very  hot  and  dry  skin,  which  is  rarely  wanting 
in  the  first  stage  of  ordinary  inflammation  of  the  brain,  was  rarely, 
if  ever,  found  in  this  disease. 

I  have  not  been  able  to  learn  much  of  the  treatment  of  this  epi¬ 
demic,  by  the  various  practitioners  who  have  had  it  to  manage ; 
but  so  far  as*  I  have  learned,  the  treatment  has  been  various,  and 
the  success  equally  so.  I  must  therefore  be  permitted  to  give  my 
own  treatment  of  it  as  it  appeared  during  the  first  spring  of  its 
prevalence,  viz.,  in  1856. 

When  called  to  children,  if  I  found  them  rational,  I  usually  com¬ 
menced  the  treatment  with  an  emetic  of  ipecac  and  followed  this 
with  a  large  dose  of  rhubarb  and  calomel,  directing  the  dose  to  be 
repeated,  or  followed  by  castor  oil  in  a  few  hours,  if  the  first  did 
not  act  promptly  and  actively.  After  which  I  kept  up  pretty  act¬ 
ive  purgation  with  calomel  and  rhubarb,  and  gave  sudorifics  in 
the  interval  until  the  disease  gave  way.  If  I  found  the  little  pa¬ 
tient,  as  I  frequently  did,  insensible,  I  at  once  gave  it  a  large  dose 
of  calomel,  and  followed  this  in  two  hours  with  as  much  croton  oil 
as  I  thought  it  would  bear.  This,  if  the  child  had  not  fallen  into 
convulsions,  would  rarely  fail  to  restore  it  to  consciousness  ;  after 
which  a  milder  course  of  purgation  was  continued,  until  the  little 
patient  was  convalescent.  Adults,  and  those  over  ten  or  twelve 
years  old,  if  the  cheeks  were  flushed,  the  pulse  full  and  strong,  and 
a  good  deal  of  heat  of  surface,  I  frequently  bled;  but  I  found  it 
important  to  be  very  careful  in  the  selection  of  cases  for  the  lancet. 
To  bleed  while  the  surface  was  cool,  although  the  patient  was  in¬ 
sensible,  was  apt  to  prove  injurious,  if  not  fatal. 

When  the  attack  seemed  violent,  and  especially  if  I  found 
the  patient  talking  incoherently,  or  lying  in  a  stupor,  whether  I 
bled  or  not,  I  gave  the  patient  at  once  a  full  dose  of  calomel,  and 
followed  it  in  from  two  to  four  hours  with  as  much  croton  oil  as  I 
thought  he  would  bear.  This  I  repeated  sooner  or  later,  according 


42 


REPOET  ON 


to  the  symptoms,  but  always  by  the  next  day.  I  think  I  never 
found  it  necessary  to  give  the  croton  oil  after  the  second  day  ;  then 
a  milder  course  of  purgation,  with  calomel  and  some  vegetable  or 
saline  purgative  was  continued,  with  tartar  emetic  and  sudorifics. 

I  could  not  discover  that  the  cases  which  I  bled  did  any  better 
than  those  which  I  did  not  bleed ;  but  when  I  did  not  bleed,  the 
more  active  purgatives  were  used.  I  soon  learned  therefore  to  bleed 
but  little  in  this  disease.  Active  purgatives  were  my  chief  reli¬ 
ance. 

After  I  had  fully  adopted  this  course  and  diligently  and  perse- 
veringly  carried  it  out,  I  had  no  reason  to  change  the  treatment,  as 
it  was  entirely  successful.  So  far  as  I  have  been  able  to  learn,  those 
who  adopt  a  milder  and  less  active  course  were  less  successful. 

When  convulsions  have  just  supervened  before  I  saw  the  patient 
I  at  first  bled,  cupped,  and  scarified,  gave  croton  oil  and  blistered 
the  occiput,  but  never  with  success,  as  I  now  remember.  I  finally 
made  it  a  rule  to  do  but  little,  after  convulsions  had  fully  set  in. 
No  case  in  my  practice  lasted  more  than  twelve  hours  after  convul¬ 
sions  came  on. 

The  second  epidemic,  that  of  1859,  was  much  milder,  and  conse¬ 
quently  required  a  much  less  active  treatment ;  but  even  here  I  found 
purgative  doses  of  calomel  a  very  important  part  of  the  treatment. 
In  no  disease  which  I  have  ever  treated,  have  I  found  calomel  and 
active  purgatives  so  imperatively  demanded  and  so  well  borne. 

As  tinct.  of  chlorid.  of  iron  is  acknowledged  to  be  a  very  im¬ 
portant  remedy  in  the  treatment  of  ordinary  erysipelas,  it  may  be 
asked  why  I  did  not  adopt  this  as  one  of  the  chief  medicines  in  the 
treatment  of  this  disease,  which  I  considered  to  be  erysipelatous  in 
its  character.  My  answer  to  this  would  be,  that  owing  to  the  deli¬ 
cate  structure  of  the  parts  attacked,  their  vital  importance  to  the 
economy,  the  violence  of  the  disease,  and  the  rapidity  with  which 
it  moved  to  a  fatal  result,  I  feared  to  trust  a  medicine  so  slow  in 
its  effects. 

I  believe  I  might  have  used  it  to  advantage  in  the  epidemic  of 
1857,  when  the  disease  was  milder  and  less  rapid  in  its  course. 
The  treatment,  however,  which  I  adopted  after  the  first  two  or 
three  cases,  in  the  previous  epidemic,  was  so  satisfactory  in  its  re¬ 
sults,  that  I  had  no  reason  to  change  it,  but  simply  to  modify  ac¬ 
cording  to  the  diminished  severity  of  the  case  or  the  strength  of  the 
patient. 

Dr.  H.  Kelly,  in  his  report  of  the  diseases  most  prevalent  in 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


43 


Iredell  County  in  the  years  1856  and  ’57,  makes  mention  of  a  cere- 
bro-spinal  meningitis  which  prevailed  epidemically  in  that  county 
during  the  winter  and  spring  of  1856.  In  some  neighborhoods  it 
was  very  fatal,  patients  frequently  dying  within  thirty-six  hours 
after  the  attack.  The  majority  of  those  who  died  only  withstood 
it  for  from  forty-eight  to  seventy-two  hours.  If  they  passed  the 
latter  period  convalescence  took  place  slowly. 

The  treatment  adopted  in  the  early  stage  of  the  disease,  was 
bleeding,  cupping,  and  blistering  to  the  back  of  the  neck  and  along 
the  spine.  Internally,  small  doses  of  calomel  and  ipecac  were  ad¬ 
ministered  every  third  hour  for  fifteen  or  eighteen  hours,  particu¬ 
larly  if  there  was  constipation  or  a  want  of  healthy  action  of  the 
liver,  which  I  always  found  to  be  the  case.  f 

It  is  of  the  utmost  importance  to  push  the  mercury  to  the  extent 
of  producing  its  constitutional  effects,  if  the  disease  is  not  speedily 
subdued.  After  the  inflammatory  symptoms  have  subsided,  the 
exhibition  of  quinine,  combined  with  small  doses  of  ipecac,  and 
occasionally  with  opium  or  morphia,  will  do  much  good.  Hot 
mustard  pediluvia  were  very  serviceable  in  restoring  warmth  to 
the  cold  extremities  and  aiding  reaction. 

Dr.  J.  J.  Summered,  of  Salisbury,  reports:  “An  occasional  case 
of  cerebro-spinal  meningitis  I  have  now  and  then  seen,  during  my 
whole  professional  career  (of  nearly  fifteen  years);  but  only  during 
the  spring  of  1856  have  I  observed  this  disease  to  assume  any¬ 
thing  of  an  epidemic  character. 

,  “At  that  time,  however,  during  the  months  of  March  and  April 
more  especially,  there  was  a  great  prevalence  of  what  we  had  been 
accustomed  to  call  catarrhal  fever  ;  a  disease  very  closely  resembling 
that  usually  described  as  such  in  the  books.  Many  of  the  children 
and  youth  of  the  community  were  the  subjects  of  its  attack. 

“The  leading  symptoms  were  drowsiness,  heat  of  skin,  rapid, 
but  rather  feeble  pulse,  dry  and  slightly  furred  tongue,  sordes  on 
the  teeth,  much  prostration  of  the  muscular  strength,  great  oppres¬ 
sion  of  the  nasal  passages,  which  were  dry,  and  in  most  cases  with¬ 
out  any  secretion  whatever,  and  such  a  turgid  condition  of  the 
Schneiderian  mucous  membrane  as  to  render  respiration  through 
the  nostrils  painful  and  difficult. 

“  When  aroused,  the  patient  complained  of  most  intense  pain  in 
the  region  of  the  frontal  sinuses.  There  were  always  marked 
symptoms  of  catarrh,  though  by  no  means  sufficient  to  account  for 


44 


REPORT  ON 


the  great  amount  of  constitutional  disturbance  present.  The  bowels 
were  generally  confined,  though  sometimes  unnaturally  loose. 

“  This  condition  of  the  patient  would  last  for  one,  two,  or  three 
days,  with  little  or  no  alteration,  when  very  generally  there  was 
observed  a  small  red  spot  on  some  part  of  the  face,  most  frequently 
on  the  eyelids  and  temporal  spaces,  slightly  tumefied  at  first,  but 
increasing  rapidly,  and  in  some  instances  becoming  so  great  as  to 
close  the  eyes  in  a  few  hours.  In  every  case  in  which  this  swelling 
or  eruption  was  well  marked,  there  was  a  speedy  amelioration  of 
all  the  graver  symptoms,  and  convalescence  dated  from  that  oc¬ 
currence. 

“This  mani£estion  of  disease  on  the  skin  was  unmistakably 
erysipelatous  in  its  character,  and  gives  a  satisfactory  clue  to  the 
nature  of  the  epidemic.  A  large  proportion  of  the  cases  terminated 
with  a  slight  erysipelatous  eruption  on  the  face ;  and  as  they  every 
one  without  exception  recovered,  this  event  was  hailed  by  the 
medical  attendant  as  the  sure  ground  upon  which  to  base  a  favorable 
prognosis. 

“But  it  was  not  always  our  good  fortune  to  behold  this  joyful 
harbinger ;  for,  occasionally,  cases  would  occur  in  which  there  were 
no  external  evidences  of  erysipelas,  but  bronchitis  or  pneumonia 
would  take  the  place  of  the  eruption,  and  these  cases,  under  judicious 
treatment,  as  a  general  thing  did  well. 

“  The  treatment,  however,  most  usually  successful  in  common 
asthenic  thoracic  inflammation  was  for  the  most  part  inadmissible 
here,  and  our  chief  reliance  in  their  management  was  on  the  stimu¬ 
lating  and  supporting  plan,  modified  according  to  circumstances, 
and  combined  with  such  mild  mercurial  impressions  as  the  asthenic 
character  of  the  disease  would  permit  with  safety. 

“  But  there  was  another  class  of  cases  (and  it  is  to  these  that  the 
attention  of  the  profession  is  particularly  directed)  which  super¬ 
vened  upon  the  early  symptoms  described ;  and  which,  from  their 
fatal  termination  and  the  peculiar  features  they  developed,  gave 
this  epidemic  its  importance,  and  made  it  a  subject  of  such  deep 
interest  to  the  physician  when  it  prevailed. 

“  In  these  were  developed  all  the  leading  symptoms  of  cerebro¬ 
spinal  meningitis.  The  sleep  gradually  advanced  to  coma,  or  the 
pain  over  the  brow,  increasing  to  a  most  excruciating  agony,  soon 
gave  place  to  the  wildest  delirium.  The  pupils  of  the  eyes  became 
in  some  cases  so  permanently  dilated  as  either  to  destroy  or  greatly 
impair  the  vision.  In  other  cases  they  were  closely  contracted. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


45 


There  was  more  or  less  stiffness  of  the  muscles  of  the  neck,  and 
a  disposition  to  opisthotonos  was  observed  in  one  case.  The  poor 
victim  soon  lost  all  consciousness,  and  gradually  sank  as  the  func¬ 
tions  of  the  brain  and  spinal  marrow  were  more  and  more  deranged, 
or,  as  I  saw  once,  general  convulsions  ended  the  scene. 

“Such  was  the  termination  of  some  of  the  cases  of  this  epidemic, 
a  disease  at  its  commencement,  precisely  similar  to  the  one  we  are 
accustomed  to  call  catarrhal  fever  ;  but  widely  differing  in  its  sequo¬ 
ias  and  results.  It  is  needless  to  say  that  these  brain-cases  almost 
always  proved  fatal.  Cerebro-spinal  meningitis,  occurring  under 
the  most  favorable  circumstances,  is  a  very  fatal  disease  ;  but  as  it 
presented  itself  in  this  epidemic,  not  one  well  marked  and  well 
authenticated  case  recovered  out  of  some  twenty  cases  occurring 
in  the  practice  of  the  physicians  of  Salisbury.  If  there  were  any 
recoveries  I  did  not  hear  of  them.  In  my  own  practice,  there  were 
none  out  of  six  cases.” 

Since  the  year  1856  erysipelas  has  prevailed  more  extensively 
in  Rowan  and  Cabarrus  counties  than  was  ever  known  before,  but 
cases  of  cerebro-spinal  meningitis  in  any  way  connected  with  it 
have  seldom  occurred.  But  whenever  it  has  supervened  on  erysi¬ 
pelas,  if  has  been  alike  fatal,  proving  an  opprobrium  to  the  healing 
art. 

At  first,  of  course,  this  disease  gave  rise  to  a  good  deal  of  dis¬ 
cussion  among  the  members  of  the  profession  and  some  diversity 
of  opinion  as  to  its  nature.  But  as  opportunities  for  observation 
were  multiplied  and  the  epidemic  more  diligently  studied  and  care¬ 
fully  analyzed,  professional  belief  seemed  to  become  unanimous,  that 
these  brain  cases,  as  well  as  those  of  bronchitis  and  pneumonia 
following  these  early  symptoms  of  catarrh  as  described,  were  no 
less  of  an  erysipelatous  character  than  were  those  where  the  erup¬ 
tion  manifested  itself  on  the  face. 

The  question  as  to  why  this  form  of  inflammation  of  the  brain 
should  be  so  much  more  fatal  than  the  ordinary  epidemics  of 
cerebro-spinal  meningitis,  as  they  have  prevailed  in  this  country 
and  in  Europe,  which  are  described  in  the  books,  finds  in  my  mind 
a  satisfactory  answer  in  the  nature  of  erysipelatous  inflammation. 

It  is  not  only  a  contagious  and  specific,  but  also  an  asthenic  in¬ 
flammation  or  disease,  and  is  always  associated  with  depression  of 
the  vital  functions  and  great  vitiation  of  the  blood.  Every  practi¬ 
tioner  will  attest  that  erysipelas  is  more  fatal  than  ordinary  sthenic 
inflammation  even  when  it  attacks  the  external  surface,  although 
4 


46 


REPORT  ON 


the  pressure  of  the  products  of  inflammation  on  important  organs, 
or  their  confined  situation  does  not  here  necessarily  offer  an  insur¬ 
mountable  obstacle  to  the  curative  powers  of  nature.  But  when 
occurring  in  structures  surrounded  by  unyielding  bony  walls  in¬ 
closing  the  brain,  the  very^  centre  of  life  giving  power,  it  seems  to 
me  not  at  all  surprising  that  this  disease  should  prove  so  fatal. 

I  have  had  no  opportunity  of  making  autopsies,  and  therefore 
cannot  speak  of  the  'post-mortem  appearances.  But  remembering 
that  the  disease  is  erysipelas  occurring  within  the  cranium,  I  think 
we  may  infer,  that  were  such  examination  made,  we  should  find 
more  diffuse  inflammation  of  the  membranes,  greater  tumefaction 
of  the  tissues,  and  a  larger  amount  of  serum  effused  than  in  sthenic 
inflammation,  besides  other  products  of  an  unorganizable  nature, 
wholly  unaccompanied  by  any  curative  adhesive  process.  Hence, 
we  argue  the  almost  necessarily  fatal  character  of  the  disease,  in 
spite  of  the  best  directed  efforts  in  the  way  of  treatment. 

Before  closing  this  notice,  it  may  not  be  improper  to  say  some¬ 
thing  of  the  treatment  pursued ;  and  a  few  general  remarks  must 
suffice. 

When  called  to  cases  of  catarrhal  fever  as  described,  at  an  early 
period  of  the  attack,  an  active  purgative  of  calomel  and  jalap  was 
usually  followed  by  some  relief  to  the  distinctive  symptoms.  The 
impression  thus  made  we  endeavored  to  keep  up  by  an  occasional 
small  dose  of  the  sub-muriate,  and  to  moderate  the  force  of  the 
heart’s  action,  by  small  doses  of  emetic  tartar;  or,  in  cases  in  which 
there  was  irritability  of  the  gastro-intestinal  mucous  membrane, 
ipecac. 

It  was  observed  that  as  soon  as  the  nasal  secretion  became  free 
the  severe  head  symptoms  abated  in  a  marked  degree.  To  assist 
in  bringing  this  about  and  to  maintain  it  afterwards,  a  small  flannel 
bag,  filled  with  fresh  hops,  and  steeped  in  hot  water,  was  laid  over 
the  brow,  and  secured  in  its  place  by  a  napkin  or  cloth  thickly  folded 
to  prevent  a  too  rapid  escape  of  warmth  and  moisture. 

Under  such  a  course  of  treatment  in  the  beginning,  and  quinine 
in  the  latter  stages,  when  the  fever  was  remittent,  as  it  was  apt  to 
be,  the  patients  soon  recovered.  When  graver  symptoms  made 
their  appearance,  constituting  pneumonia  or  bronchitis,  the  treat¬ 
ment,  as  before  intimated,  had  to  be  conducted  on  the  supporting 
and  stimulant  plan,  rather  than  by  depletion  and  depressing  agents. 

When  the  membranes  of  the  brain  and  spinal  marrow  became 
the  seat  of  the  disease,  local  or  general  depletion,  in  some  cases 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


47 


which  seemed  to  require  it,  calomel,  mercurial  alteratives,  blisters 
to  different  parts  of  the  scalp  and  spine,  and  the  hyd.  potass,  were 
the  remedies  usually  tried,  but  were  all  alike  found  to  be  unavail¬ 
ing.  The  patients  died  in  almost  every  such  case,  while  the  treat¬ 
ment  seemed  to  exercise  no  influence  whatever  in  postponing  the 
fatal  issue. 

The  muriated  tincture  of  iron,  which  seems  to  exert  an  almost 
specific  influence  over  erysipelas  occurring  in  other  parts  of  the 
body,  I  was  deterred  from  using  by  a  remark  made  by  Professor 
Barlow  in  relation  to  it  in  such  cases.  He  says  (speaking  of  the 
treatment  of  erysipelas),  u  in  severe  cases,  where  there  is  no  head 
affection,  the  sesquichloride  of  iron,  in  doses  of.  ten  minims  of  the 
tincture,  three  or  four  times  a  day,  appears  to  be  almost  a  specific.” 

But  after  some  reflection  on  the  subject,  I  am  persuaded  that 
there  is  no  sufficient  reason  for  withholding  the  remedy,  notwith¬ 
standing  the  warning  of  the  Professor ;  because  all  other  modes  of 
treatment  have  effected  next  to  nothing  in  staying  its  destructive 
power. 


DYSENTERY. 

Dysentery,  like  the  preceding  epidemics  of  this  State,  prevails 
throughout  its  entire  extent,  from  the  mountains  to  the  sea  shore. 
Dr.  Hackett,  of  Wilkesboro,  on  the  summit  of  the  Blue  Ridge,  de¬ 
scribes  it  as  a  prevalent  disease  in  that  region;  Dr.  McKee,  of  Raleigh, 
reports  it  occurring  in  the  middle  region  of  the  State,  while  Dr.  Cox, 
of  Perquimans  County,  in  the  extreme  east  and  on  the  sea  shore, 
describes  it  as  one  of  the  ordinary  epidemics  of  that  portion  of 
the  State. 

The  type  of  this  disease  has  been  a  mild  one  for  some  years 
past,  at  least  so  far  as  it  has  prevailed  in  this  city  (Wilmington) 
and  as  reported  to  me  from  other  localities.  It  is  a  rare  thing  of 
late  to  meet  with  those  formidable  cases,  which  were  of  frequent 
occurrence  twenty  years  ago,  and  which  approximated  in  severity 
to  the  tropical  forms  of  the  disease,  as  described  by  Johnson  and 
Annesley. 

In  this  locality,  it  prevails  most  generally  in  the  months  of  June, 
July,  and  August,  and  seems  to  be  ordinarily  concurrent  with  inter¬ 
mittent  and  remittent  fevers.  Some  of  our  physicians,  indeed,  are 
inclined  to  regard  it  as  a  malarial  disease,  and  to  attribute  it  to 
the  same  cause  which  they  regard  as  productive  of  remittent  and 


48 


REPORT  ON 


intermittent  fevers,  with  the  superaddition  of  some  modifying  cir¬ 
cumstance,  which  determines  the  expenditure  of  its  force  on  the 
mucous  surface  of  the  large  intestines. 

This  view  of  its  etiology  can  hardly  be  regarded  as  tenable  at 
present,  when  we  consider  that  it  prevails  in  the  mountain  district, 
where  as  yet  intermittents  and  remittents  never  originate  spontane¬ 
ously. 

For  the  present,  we  must  regard  it  as  the  result  of  a  widely 
spread  atmospheric  distemperature,  or  of  causes  which  are  not 
limited  to  any  particular  locality  in  the  State. 

This  disease  is  for  the  most  part  amenable  to  treatment,  and 
yields  readily  to  a  combination  of  laxative  and  anodyne  medicines ; 
and  as  the  liver  is  generally  supposed  to  be  implicated  in  the 
morbid  action  which  is  going  on  in  the  system,  mercurials  are 
usually  selected  as  the  laxative  ingredients  in  the  prescription. 
If  not  used  indiscriminately  or  pushed  too  far  it  must  be  admitted 
that  they  are  useful  and  perhaps  at  times  indispensable  remedies  in 
the  treatment  of  this  disease,  but  they  are  not  now  used  as  freely 
as  they  formerly  were  in  the  treatment. 

In  some  decidedly  severe  cases  I  have  recently  seen  good  results 
from  the  use  of  large  doses  of  ipecac,  as  recommended  by  a  writer 
in  a  late  number  of  the  London  Lancet.  By  premising  an  opiate 
the  stomach  can  be  made  to  tolerate  it  in  large  doses,  by  which 
means  it  is  rendered  decidedly  more  efficient  than  when  used  in  the 
small  nauseating  doses  in  which  it  is  more  commonly  adminis¬ 
tered. 

In  the  more  advanced  stages  of  the  disease,  bals.  copaiba,  in  com¬ 
bination  with  mucilage  of  gum  Arabic,  andtinct.  opii,  is  found  to  be 
serviceable.  With  some  of  our  physicians,  acet.  plumb,  with  opium 
is  a  favorite  prescription  under  such  circumstances. 

CHOLERA  INFANTUM. 

This  is  one  of  our  confirmed  endemics,  and  is  apt  to  ^prevail  epi¬ 
demically  both  in  spring  and  autumn.  Like  dysentery,  this  is 
regarded  by  many  as  belonging  to  the  same  generic  class  of  maladies 
of  which  intermittent  and  remittent  fevers  constitute  the  type. 
There  would  seem,  however,  to  be  very  little  foundation  for  such 
an  opinion.  The  mere  circumstance  of  their  prevailing  concur¬ 
rently,  can  hardly  be  esteemed  a  satisfactory  reason  for  assigning 
to  them  the  same  origin. 


THE  EPIDEMICS. OF  NORTH  CAROLINA. 


49 


To  some  extent,  indeed,  the  same  causes  may  be  regarded  as  co¬ 
operating  in  the  production  of  both  classes  of  disease.  This  is 
probably  true  as  regards  high  atmospheric  temperature,  which  may 
be  regarded  as  essential  and  common  to  both  fevers  and  cholera  in¬ 
fantum.  Sudden  changes  of  temperature  may  also  be  regarded  as 
equally  operative  in  the  production  of  both  forms  of  disease. 

Beyond  these,  however,  there  are  probably  no  causes  which  can 
be  regarded  as  common  to  both  classes  of  maladies,,  and  what  may 
be  the  occult  causes  which  determine  the  one  or  the  other  form  of 
disease  will  probably  continue  to  be  a  matter  of  speculation. 

Of  course,  the  time  of  life  is  one  of  the  conditions  which  is  pe¬ 
culiar  to  cholera  infantum.  Errors  in  diet  also  are  more  directly 
efficient  exciting  causes  in  cholera  infantum  than  in  fever,  though 
not  without  influence  in  the  latter  form  of  disease  also. 

In  almost' all  the  cases  of  this  disease,  the  stomach  is  relieved  of 
its  irritating  contents  by  spontaneous  vomiting,  so  that  the  first 
indication  which  generally  presents  itself,  is  to  quiet  the  irritation 
of  that  organ  and  of  the  bowels,  and  at  the  same  time  gently  relieve 
the  latter  of  any  offending  matter  which  they  may  contain. 

This  may  generally  be  accomplished,  not  by  opiates,  but  by  the 
milder  mercurials,  such  as  hydrarg.  c.  creta,  or  the  sub-muriate  of 
mercury.  The  calomel  I  have  generally  found  to  be  most  certain 
and  efficient. 

After  the  operation  of  the  mercurial,  the  treatment  must  consist 
in  the  proper  regulation  of  the  diet,  with  the  use  of  antacids,  ab¬ 
sorbents,  opiates,  and  astringents,  as  may  be  indicated  by  the  symp¬ 
toms.  In  very  severe  cases,  opiates  are  essential  very  early  in  the 
treatment  of  the  case;  but  as  a  general  rule  opiates  are  not  pro¬ 
ductive  of  benefit  in  the  early  stages.  In  protracted  cases  they 
constitute,  together  with  diffusible  stimuli,  our  chief  dependence. 

STOMATITIS. 

This  disease  prevailed  so  extensively  in  the  early  part  of  the 
summer  of  1858,  as  to  be  fairly  entitled  to  the  character  of  an  epi¬ 
demic. 

The  most  common  form  which  the  disease  assumed,  was  the 
aphthous  or  follicular;  some  of  the  cases  took  the  form  of  simple 
erythematous  inflammation  of  the  buccal  mucous  membrane. 

One  case  of  the  pustular  variety  of  the  disease  occurred,  in  which 


50 


REPORT  ON 


the  tongue  and  mucous  surface  of  the  mouth  were  covered  with 
pustules  resembling  very  much  the  pustules  of  variola  discreta. 

I  saw  no  cases  of  the  diphtheritic  or  pseudo-membranous  form  of 
the  disease,  nor  have  I  been  able  to  hear  of  its  prevalence  in  this 
form  in  any  other  part  of  the  State. 

A  few  of  the  cases  were  attended  with  slight  febrile  disturbance 
and  headache,  with  gastric  disorder.  As  there  was  usually  some 
constipation,  a  mild  purgative  was  ordinarily  prescribed,  and  as 
the  complaint  was  generally  attended  with  symptoms  indicative  of 
acidity  of  the  stomach,  the  common  eccoprotic  rhubarb  and  mag¬ 
nesia  was  the  formula  generally  selected. 

If  the  case  was  at  all  obstinate,  an  emetic  of  ipecacuanha  would 
often  exert  a  salutary  influence. 

Astringent  washes  and  the  occasional  use  of  a  solution  of  the 
nitrate  of  silver,  constituted  the  local  treatment. 

It  may  not  be  amiss  to  notice,  as  evincing  a  very  peculiar  and 
unusual  epidemic  constitution  of  the  atmosphere ,  that  about  the  period 
of  the  prevalence  of  this  epidemic  stomatitis,  a  disease  bearing  some 
resemblance  to  it,  originated  and  prevailed  very  extensively  among 
domestic  cattle,  and  among  some  of  the  ferae  naturae ,  a  form  of 
fever  very  fatal  in  its  effects,  and  whose  most  striking  characteristic 
was  an  inflamed,  ulcerated,  and  sometimes  gangrenous  condition  of 
the  tongue. 

Duringthe  prevalence  of  this  epidemic,  the  hunter  very  frequently 
came  across  the  carcasses  of  deer  in  every  stage  of  decomposition 
and  with  the  characteristic  black  mouth. 

JAUNDICE. 

This  disease  has  frequently,  of  late  years,  assumed  the  epidemic 
form  and  prevailed  extensively.  The  year  1847  was  characterized 
by  the  extensive  prevalence  of  jaundice,  in  this  city  (Wilmington), 
in  the  summer  and  autumnal  months.  There  was  at  the  same  time 
a  remarkable  exemption  from  the  ordinary  climatic  fevers  of  the 
season. 

Whether  the  morbific  cause,  or  causes  which  ordinarily  produce 
intermittent  and  remittent  fevers,  had  any  agency  in  the  produc¬ 
tion  of  the  epidemic  icterus,  I  will  not  undertake  to  determine.  It 
may  well  be  regarded  as  highly  probable  that  it  had,  inasmuch  as 
the  jaundice  seemed  to  replace  the  ordinary  endemic  diseases. 

If  we  are  correct  in  ascribing  it  to  such  agency,  it  furnishes  a 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


51 


rare  example  of  the  action  of  the  morbific  cause  of  fever,  on  a  single 
organ  of  the  body. 

The  summer  and  fall  of  1847  were  not  remarkable  for  any 
striking  meteorological  peculiarities  which  ‘could  account  for  the 
appearance  or  production  of  the  disease.  Its  type  was  for  the  most 
part  very  mild,  but  few  persons  being  confined  to  bed  with  it,  and 
in  many  cases  it  was  treated  by  domestic  remedies  alone.  A  mild 
mercurial  cathartic  or  an  emetic  seemed  to  be  all  that  was  required 
in  the  great  majority  of  cases.  The  more  obstinate  cases  yielded 
to  the  iodide  of  potass.  In  some  cases  quinine  was  found  to  be  a 
useful  remedy. 

Dr.  Whitehead,  of  Salisbury,  reports  that  in  September  (1858), 
an  unusual  number  of  cases  of  jaundice  occurred  in  the  practice  of 
the  physicians  of  Salisbury  and  in  the  county  of  Rowan.  The 
first  cases  were  amongst  some  negroes  employed  on  a  brickyard 
in  the  suburbs,  and  the  hands  employed  on  the  North  Carolina  and 
Western  Railroad. 

“We  soon  found,  from  the  numerous  cases  occurring  in  town  and 
county,  that  we  had  an  epidemic  to  deal  with.  The  first  symp¬ 
toms  were  great  pain  in  the  right  and  left  hypochondriac  regions, 
extending  round  the  body,  and  in  some  cases  over  the  whole  abdo¬ 
men  ;  nausea  and  vomiting,  bowels  constipated,  urine  loaded  with  « 
bile.  Cups,  mustard  plasters,  and  warm  fomentations  to  the  abdo¬ 
men,  a  large  dose  of  calomel  and  opium,  followed  in  a  short  time 
with  either  a  dose  of  castor  oil  and  turpentine,  or  cream  of  tartar 
and  jalap,  soon  relieved  the  pain. 

“In  a  few  hours  after  the  bowels  were  opened,  the  patient  would 
be  jaundiced.  No  biliary  calculi  were  passed  that  we  could  dis¬ 
cover.  The  disease  seemed  to  depend  upon  gastro-duodenal  irrita¬ 
tion,  or  a  clogging  up  of  the  biliary  ducts  with  inspissated  bile. 
So  soon  as  the  patient  was  well  purged,  the  free  use  of  taraxacum, 
soda  and  nitre,  with  an  occasional  purgative  of  cream  of  tartar  and 
jalap,  completed  the  cure. 

“There  were  two  fatal  cases;  both  women  in  childbed.  One  died 
in  twenty,  the  other  in  twenty-six  hours  after  the  birth  of  the  child. 
Not  a  drop  of  urine  was  secreted  in  either  case  .after  the  birth  of 
the  child.” 

Dr.  Bedford  Brown,  of  Caswell  County,  reports  “that  jaundice 
prevailed  epidemically  in  that  region  of  the  State,  in  the  year  1857, 
accompanied  in  some  instances  with  remittent  fever.  Active  mer- 


52 


REPORT  ON 


curia!  cathartics,  and  sulph.  quinine,  when  fever  was  present,  usually 
afforded  relief. 

UI  consider  this  epidemic  of  jaundice  as  a  line  of  demarcation 
between  the  typhoid  and  active  inflammatory  types  of  morbid  in¬ 
fluences  in  our  region.  Since  its  disappearance,  we  no  longer  fear 
the  adoption,  or  doubt  the  propriety  of  using  antiphlogistic  reme¬ 
dies.” 

Dr.  Wm.  Cramer,  of  Beaufort,  in  Hyde  County,  reports  the  ex¬ 
tensive  prevalence  of  jaundice  in  that  place,  in  autumn  of  the  year 
1857.  He  says,  in  the  early  part  of  November,  a  disease  of  an  epi¬ 
demic  character  was  developed  to  an  unusual  extent.  “  I  think  I 
may  safely  say  that  one-half,  if  not  two-thirds  of  the  adult  popula¬ 
tion  of  this  town  and  vicinity,  are  or  have  been  affected  by  it. 
This  disease  is  jaundice.  Yery  few  under  twenty  years  of  age  have 
been  attacked  ;  but  between  twenty  and  thirty  many,  between  thirty 
and  forty  more,  and  between  forty  and  fifty  still  more. 

“  This  disease  generally  came  on  gradually,  with  depression  of 
spirits,  languor,  and  watchfulness,  bowels  constipated,  tongue  thickly 
coated  with  a  yellow  covering,  sometimes  dry  and  whitish  yellow. 
Alvine  evacuations  light  or  clay  colored.  In  very  few  cases  there 
was  vomiting,  in  many  there  was  nausea.  Yery  little  pain  in  most 
cases,  but  a  sense  of  constriction  about  the  epigastrium  and  abdo¬ 
men  (to  use  the  expression  of  persons  affected),  as  though  a  wide 
band  or  belt  was  pressing  against  them.  The  urine  was  generally 
very  thick  and  muddy,  and  sometimes  of  a  deep  mahogany  color, 
the  conjunctiva  yellow,  and  a  dusky  yellowness  of  the  whole  body. 
In  some  cases,  there  was  great  itching  of  the  surface. 

“  All  of  the  cases  yielded  readily  to  treatment,  and  I  have  heard 
of  none  proving  fatal. 

“  The  usual  treatment  is  to  give  a  dose  of  comp,  cathart.  pills, 
followed  by  rhubarb  and  magnesia  if  they  fail  to  operate  well ; 
then  comp,  tinct.  of  rhub.  and  aloes,  twice  a  day,  to  keep  the  bowels 
free.  If  necessary,  in  a  day  or  two  to  repeat  the  pills.  The  first 
operations  from  the  pills  are  dark  and  tarry.  When  the  evacuations 
show  bile,  continue  the  tincture,  and  give  acid,  nitric,  ten  drops  three 
times  a  day  ;  sometimes  a  large  dose  of  pulv.  Dover!  at  night.  In  a 
few  cases  I  have  given  a  full  dose  of  calomel  and  Dover’s  powder 
at  night,  and  followed  it  by  rhubarb  and  magnesia  in  the  morning. 

a  This  disease  between  the  early  part  of  December  and  the  mid¬ 
dle  of  January,  had  nearly  or  quite  subsided ;  but  about  the  middle 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


58 


of  February,  it  commenced  again,  and  is  still  prevailing  at  this 
time  (March)  as  extensively  as  before. 

“There  has  been  nothing  in  the  weather  which  I  can  assign  as 
a  cause  for  the  prevalence  of  this  form  of  disease.  The  winter  has 
been  mild,  with  no  more  than  the  usual  quantity  of  rain. 

“  It  may  be  proper  to  state,  that  pneumonia  has  been  more  pre¬ 
valent  than  usual  during  the  months  of  December,  January,  and 
February,  and  attacked  persons  in  preference  who  had  been  jaun¬ 
diced. 

“  In  submitting  the  above  remarks,  it  is  natural  to  inquire  what 
peculiar  state  of  things  has  produced  this  almost  universal  jaundice, 
as  it  is  certainly  of  very  rare  occurrence. 

“  During  the  fall  and  early  part  of  the  winter,  as  stated  before, 
a  universal  predisposition  to  typhoid  fever  existed,  producing 
such  depression  of  the  nervous  system  and  such  torpor  of  all  the 
secretory  organs,  that  the  ordinary  changes  of  temperature,  aided 
by  the  indolent  habits  of  the  inhabitants  of  this  town  and  vicinity, 
were  sufficient  to  favor  its  development  of  the  disease.  From  the 
foregoing  considerations,  it  is  evident  to  my  mind  that  jaundice, 
when  it  prevails  epidemically,  has  its  origin  in  the  brain  and  nerv¬ 
ous  system.  The  nervous  energy  being  withheld  from  the  mov¬ 
ing  forces  of  the  system,  the  bile  is  either  deteriorated  or  lessened 
in  quantity,  or  obstructed  in  its  passage  into  the  duodenum. 

“In  dyspepsia  we  find  the  same  principle  holds  good.  After 
strong  emotions  of  the  mind,  or  after  intense  effort  at  study,  or 
dwelling  intensely  on  one  subject,  the  nervous  energy  necessary 
to  carry  on  the  healthy  operations  of  the  stomach  and  digestive 
organs  is  suspended,  or  withheld  from  these  organs,  and  they  are 
all  disordered  and  the  disease  readily  developed. 

“  Taking  this  view  of  the  subject,  I  am  led  to  believe  that  the 
peculiar  condition  of  the  nervous  systems  of  our  citizens,  from  the 
predisposition  to  typhoid  fever,  has  subjected  them  to  the  disease 
in  question,  from  the  slightest  exciting  causes.” 

Dr.  A.  B.  Pierce,  of  Halifax  County,  reports  that  there  was  one 
disease  which,  from  its  rare  occurrence  as  an  epidemic,  deserves 
some  notice.  This  disease  is  jaundice,  which  prevailed  in  Septem¬ 
ber  and  October  of  1858  in  the  town  of  Halifax.  It  was  confined 
almost  exclusivelv  to  the  town,  and  there  were  some  twenty-five  or 

4/  • 

thirty  cases  in  a  population  of  two  or  three  hundred.  From  what 
we  could  understand,  it  presented  the  usual  characteristics  of  the 


54 


KEPOKT  ON 


disease,  only  it  seemed  to  be  the  essential  disease,  the  primary  affec¬ 
tion,  instead  of  the  sequel  of  some  other  disease. 

In  some  cases  it  set  in  with  chill  and  fever,  which  lasted  for 
several  days,  and  in  others  there  seemed  to  be  little  or  no  fever 
during  the  whole  time  of  its  continuance.  There  was  scarcely  any 
form  of  malarial  disease  prevailing  during  the  same  season,  with 
the  exception  of  a  few  cases  of  continued  or  typhoid  fever.  It  is 
worthy  of  remark  that  the  first  case  occurred  in  the  person  of  a 
stranger  who  came  to  the  place  with  it. 

The  treatment  was  the  same  usually  pursued  in  jaundice. 

PNEUMONIA. 

This  disease  must  be  regarded  as  the  great  endemic  of  the  winter 
and  spring  seasons  of  the  year,  in  this  State,  prevailing  in  all  parts 
of  the  same,  whether  on  the  seaboard,  on  the  plains,  or  in  the 
mountains,  and  prevailing  so  extensively  in  almost  every  year  as 
frequently  to  be  fairly  entitled  to  the  character  of  an  epidemic. 

It  assumes,  too,  all  the  varieties  of  the  malady  known  and 
described  by  systematic  writers,  from  the  most  exalted  form  of 
sthenic  inflammation  to  the  gravest  type  of  the  adynamic  and  con¬ 
gestive  varieties.  For  the  most  part,  of  late ,  the  type  of  the  disease 
has  been  subacute  in  its  character,  rarely  acquiring  the  very  active 
depletory  and  antiphlogistic  treatment  which  was  deemed  necessary 
in  years  past. 

The  great  majority  of  the  cases  now  occurring  may  be  treated 
without  resorting  to  the  use  of  the  lancet.  Local  bleeding,  anti- 
monials.  and  recently  the  verat.  viride,  seem  to  be  capable  of  con¬ 
trolling  its  progress,  and  yet  cases  are  continually  occurring  which 
cannot  be  safely  or  prudently  managed  without  the  use  of  general 
bloodletting. 

To  attempt  to  ignore  the  experience  of  the  profession  in  all  ages 
and  in  all  countries,  as  to  the  efficacy  of  bloodletting  (and  its  indis¬ 
pensable  necessity  in  some  cases)  in  the  treatment  of  acute  inflam¬ 
matory  disorders,  is  altogether  idle. 

The  deservedly  high  reputation  of  Dr.  Bennett,  of  Edinburgh, 
and  Dr.  Todd,  of  London,  who  seem  to  consider  the  use  of  this 
remedy  as  opposed  to  all  sound  pathology,  should  not  weigh  a 
feather  in  the  determination  of  the  general  question,  whatever 
weight  we  may  be  disposed  to  give  it  in  reference  to  the  particular 


THE  EPIDEMICS  OF  NOBTH  CAKOLINA. 


55 


type  of  inflammatory  diseases  which  have  prevailed  in  their  re¬ 
spective  localities. 

It  would  surely  be  very  unsafe  for  ns  in  this  country  to  treat 
pneumonia  or  pericarditis  with  brandy  and  ammonia  instead  of 
bleeding  and  antimonials,  on  the  authority  and  recommendation  of 
London  and  Edinburgh  physicians,  except  in  those  rare  cases,  or 
epidemics  which  now  and  then  occur,  and  which  are  characterized 
by  prostration  of  the  vital  forces  amounting  almost  to  collapse. 

We  have  in  the  veratrum  viride  (a  medicine  recently  introduced 
into  practice)  a  remedy  of  great  efficacy  in  the  treatment  of  pneu¬ 
monia,  and  one  which  may  in  many  cases  safely  supersede  the  use 
of  the  lancet;  but  certainly  not  in  all  cases. 

When  the  inflammatory  action  is  of  a  high  grade,  as  indicated 
by  a  sharp  quick  pulse,  and  great  heat  of  skin,  bloodletting  both 
general  and  local  will,  I  apprehend,  still  be  found  indispensable. 

I  have  certainly  found  it  to  be  so  in  many  cases,  and  I  have 
repeatedly  found  the  veratrum  to  fail  in  the  exercise  of  any  salu¬ 
tary  influence.  In  one  instance,  even  as  an  auxiliary  measure, 
after  general  and  local  bleeding  it  failed  to  subdue  the  vascular 
excitement,  although  it  was  perseveringly  used  for  forty-eight 
hours. 

In  reference  to  the  use  of  bloodletting  in  pneumonia,  it  will  be 
well  for  us  to  be  governed  by  the  wise  injunction  of  Chomel,  not 
to  treat  diseases,  but  to  treat  patients  affected  with  disease,  and  to 
endeavor  to  adapt  our  remedies  to  the  special  requirements  of  the 
'case  before  us.  By  so  doing  we  will  be  very  apt  to  avoid  extremes 
of  opinion  and  practice,  and  fall  into  that  “  middle  way,”  in  which 
safety  is  generally  to  be  found. 

In  some  cases  of  puerperal  pneumonia  occurring  in  my  practice, 
I  have  found  the  tinct.  verat.  virid.  a  very  valuable  remedy.  This 
complication  is  a  very  formidable  one,  the  cases  often  proving  fatal 
under  any  form  of  treatment. 

In  one  instance  in  which  the  lancet  did  not  appear  to  be  indi¬ 
cated,  the  case  was  treated  by  the  veratrum  alone,  with  the  excep¬ 
tion  of  an  occasional  dose  of  pulv.  ipecac,  cp.,  and  thus  conducted  to 
a  favorable  issue.  In  another  instance  of  the  same  form  of  pneu¬ 
monia,  it  was  deemed  necessary  to  bleed  freely  and  to  repeat  the 
bleeding,  after  which  the  veratrum  apparently  aided  materially  in 
the  successful  treatment  of  the  case.  Dr.  Bedford  Brown,  of  Yan¬ 
cey  ville,  Caswell  County,  reports  an  epidemic  of  typhoid  pneumonia, 
which  prevailed  in  the  winter  of  1857-8,  and  spring  of  1858,  in 


56 


REPORT  ON 


that  county.  The  paper  describing  this  epidemic  was  published 
in  the  Am.  Journ.  of  Med.  Sciences  for  October,  1858,  from  which  I 
extract  it  as  presenting  a  rare  form  of  the  disease. 

“  The  winter  and  spring  months  of  1857  and  8  were  characterized 
by  much  wet  and  changeable  weather,  which  gave  rise  to  a  very 
extensive  epidemic  of  malignant  typhoid  pneumonia.  About  forty 
cases  came  under  the  observation  of  my  partner  Dr.  Eoan  and 
myself.  The  access  of  the  attack  was  generally  sudden,  and  with 
but  little  premonition ;  the  victim  having  been  in  the  apparent 
enjoyment  of  health  but  a  few  hours  previous.  •  The  earliest 
symptom  was  an  acute  pain  in  some  part  of  the  body,  some¬ 
times  in  the  head  or  chest,  shoulder,  hip-joint,  and  occasionally  in 
the  foot.  This  was  followed  in  rapid  succession  by  a  distinct  chill, 
which  frequently  lasted  for  hours,  and  was  always  attended  with 
excessive  vital  prostration.  It  was  not  uncommon  to  find  a  patient 
twelve  hours  after  the  first  accession  of  the  chill,  with  his  system 
sinking  down  without  the  first  effort  at  reaction.  The  pectoral 
symptoms  were  not  usually  troublesome.  The  patients  complained 
more  of  simple  uneasiness  than  actual  suffering  or  pain.  In  fact, 
the  nervous  sensibilities  were  too  much  blunted  by  morbid  influ¬ 
ences  to  feel  conscious  of  diseased  sensations  or  impressions.  This 
destruction  of  the  nervous  energies  and  sensibilities,  and  want  of 
consciousness,  was  a  remarkable  feature  in  the  disease. 

“  Another  alarming  and  constant  concomitant  symptom  was 
vital  prostration.  In  many,  the  constitutional  power  seemed  to  be 
too  low  to  generate  a  reactive  fever.  Patients  remained  cold, 
almost  pulseless,  and  unconscious  for  days,  and  were  only  sus¬ 
tained,  even  at  this  low  point,  by  powerful  stimulants,  before  any 
improvement  in  the  symptoms  occurred. 

“In  all  cases,  without  an  exception,  the  pulse  was  remarkable  for 
two  characteristics,  extreme  feebleness  and  diminution  of  volume, 
while  it  varied  much  in  frequency,  often  at  one  hundred  and  fifty, 
and  not  unfrequently  at  seventy.  In  one  patient,  I  observed  it  at 
several  of  my  morning  visits  at  forty,  while  in  the  evening  it 
numbered  about  seventy.  Frequently  patients  would  be  found 
early  in  the  morning  without  any  perceptible  pulse,  and  uncon¬ 
scious.  This  I  witnessed  in  several  instances,  and  all  reacted  under 
the  influence  of  active  and  plentiful  stimulation.  I  have  never 
observed  any  disease,  in  my  own  experience,  in  which  the  powers 
of  life  can  ebb  so  low  and  be  made  to  flow  back  to  a  state  of  health. 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  57 

by  the  judicious  and  prompt  administration  of  remedies,  as  typhoid 
pneumonia. 

.  “Most  of  the  cases  were  attended  with  a  peculiar  low  remitting 
form  of  fever,  that  had  usually  an  exacerbation  at  evening,  which 
seemed  to  act  as  a  stimulus  to  the  patient  and  bolster  him  up  for 
a  time ;  but  during  the  night  and  morning  a  corresponding  remis¬ 
sion  would  come  on,  that  invariably  reduced  the  patient’s  powers 
proportionately  low.  In  the  appearance  of  the  tongue  there  was 
nothing  constant.  In  some  cases  it  was  red  and  dry,  while  in 
others  it  was  soft,  moist,  and  white ;  occasionally  it  was  livid. 
Diarrhoea  was  occasionally  present.  Symptoms  of  a  nervous  cha¬ 
racter  were  prominently  developed  in  nearly  all  cases.  Low  mut¬ 
tering  delirium  and  subsultus  were  very  common.  Stupor  and 
somnolence  were  almost  invariably  present.  In  one  singular  case 
a  paralysis  confined  to  the  muscles  of  deglutition,  existed  for 
several  days  before  improvement  commenced. 

“Among  the  pectoral  symptoms  cough  was  usually  not  trouble¬ 
some,  neither  was  pain  in  the  chest  complained  of  any  great  deal. 
In  many  of  our  worst  cases,  both  these  symptoms  were  entirely 
absent,  or  were  not  complained  of.  Dyspnoea  was  very  distressing- 
in  only  a  few  cases.  The  presence  of  these  indications  in  a  well 
developed  form  was  good  evidence  of  a  more  sthenic  type  of  pneu¬ 
monia. 

“  The  expectoration  in  the  early  stages  was  usually  composed  of 
thin  bloody  mucus,  whilst  in  many  others  it  was  almost  purely 
^sanguineous,  partaking  of  the  hemorrhagic  character.  The  ap¬ 
pearance  of  muco-purulent  expectoration  always  denoted  improve¬ 
ment.  Out  of  nearly  fifty  cases,  I  have  witnessed  but  three  with 
genuine  rust-colored  expectoration.  The  presence  of  this  matter 
invariably  indicated  pneumonia  of  the  sthenic  form,  and  was  a  good 
criterion  for  depletive  treatment. 

“  Of  the  physical  signs,  percussion  elicited  dulness  over  the  whole 
extent  of  the  pulmonic  disease.  The  fine  crepitant  rale  of  active 
pneumonia  I  never  was  able  to  discover  in  the  typhoid ;  as  a 
substitute,  a  coarse  sub-crepitant  rale  generally  existed ;  sometimes 
in  a  few  hours  after  the  attack  there  was  an  absence  of  all  sounds. 
When  improvement  commenced,  in  place  of  the  redux  crepitation, 
the  ordinary  submucous  rales  appeared. 

“  It  was  a  little  remarkable  that,  in  all  the  female  patients  except 
one,  there  was  a  return  of  the  menstrual  period  in  a  day  or  two 


58 


REPORT  ON- 


after  the  attack  of  pneumonia.  The  exception  spoken  of  did  not 
menstruate  during  the  pneumonic  attack,  and  died. 

“  During  the  course  of  the  disease,  emaciation  progressed  with 
great  rapidity.  In  many,  a  few  days  sufficed  to  reduce  the  tissues 
like  an  attack  of  Asiatic  cholera.  Another  peculiar  symptom 
always  present  in  the  colored  patients,  was  a  dark  jaundiced  ap¬ 
pearance  of  the  sclerotic  coat  of  the  eye. 

“  The  evidences  are  strong  in  favor  of  the  conclusion  that  much 
of  the  fatality,  in  cases  of  typhoid  pneumonia,  is  due  to  the  poison 
of  carbonaceous  matter  being  retained  in  the  circulation.  It  is  per¬ 
fectly  obvious  that  when,  as  is  often  the  case,  one-half  and  even 
more  than  that  extent,  of  the  pulmonary  circulation,  is  in  a  com¬ 
plete  state  of  obstruction,  at  least  half  the  entire  amount  of  blood 
must  be  thrown  out  of  the  general  circulation,  and  remain  stagnant 
in  the  system. 

“  Another  difficulty  here  presents  itself,  in  the  inability  of  the 
heart  and  arteries  to  push  the  column  of  blood  through  the  ob¬ 
structed  lungs.  It  is  also  probable  that  the  vitality  of  both  the  blood 
and  capillaries,  is  so  far  annihilated  in  these  cases,  that  the  mutual 
affinities  between  the  fluids  and  the  solids  are  lost,  affording 
another  cause  for  the  arrest  of  circulation. 

“  As  some  proof  of  this  theory,  while  the  nervous  and  vital  ener¬ 
gies  were  crushed  with  the  rapidity  and  force  of  a  narcotic  poison, 
the  complexion,  in  white  patients,  presented  the  lividity  of  a  person 
breathing  carbonic  acid  gas. 

“  Treatment. — The  indications  of  treatment  in  these  cases,  were  of 
a  threefold  character :  first,  to  arouse  the  vital  energies  ;  secondly, 
to  push  the  stagnant  blood  through  the  obstructed  pulmonary 
capillaries  and  equalize  the  general  circulation ;  and  thirdly,  by 
means  having  a  more  permanent  influence,  to  subdue  the  latent 
inflammation  peculiar  to  typhoid  pneumonia.  We  discarded  most 
of  the  standard  rules  for  treating  sthenic  pneumonia,  and  marked 
out  a  course  to  suit  the  peculiar  characteristics  of  the  prevailing 
epidemic. 

“To  arrest  the  sudden,  rapid,  and  dangerous  prostration  that  was 
such  an  alarming  feature  of  the  disease,  diffusible  stimulants  and 
nourishment  in  the  form  of  brandy,  milk  punch  and  ammonia  were 
administered  freely  and  without  reserve,  from  the  beginning  of  the 
treatment.  Without  them,  some  cases  would  have  died  in  six 
hours.  The  amount  of  stimulants  given  depended  entirely  on  the 
exigencies  of  the  case.  Some  patients  consumed  a  quart  of  brandy 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


59 


per  day — not  for  one  day  only,  bat  for  many  in  succession,  and 
recovered  without  injurious  consequences. 

“At  a  morning  visit,  on  one  occasion,  to  a  patient,  I  found  her 
cold,  unconscious,  and  pulseless;  brandy  in  ounce  doses  was  for¬ 
cibly  poured  down  her  throat  every  fifteen  minutes,  and  under  its 
influence  I  could  perceive  the  slow  and  gradual  development  of  the 
pulse,  and  a  return  of  warmth  to  the  surface.  At  first  the  pulsa¬ 
tions  numbered  about  twenty,  and  were  scarcely  perceptible  to  the 
touch ;  but  increasing  in  a  few  hours  while  I  remained,  they  re¬ 
covered  sufficient  volume  and  strength  to  sustain  the  patient.  At 
my  next  daily  visit,  the  nurse  informed  me  that  she  had  given  the 
patient  more  than  a  quart  of  brandy  by  measurement,  during  the 
twenty  four  hours,  with  decided  benefit.  This  patient  ultimately 
recovered. 

“It  was  our  usual  custom  to  administer  brandy  in  ounce  doses, 
every  hour  or  two  according  to  the  demands  of  the  case.  In  com¬ 
bination  with  stimulants,  diet  of  the  most  nourishing  and  digestible 
kind  was  as  regularly  enjoined  as  the  remedies.  I  thought  the 
rich  milk  punch  combined  these  qualities  to  a  greater  degree,  and 
suited  the  cases  better  than  any  other  article. 

“As  an  adjuvant  to  other  remedies,  I  cannot  speak  too  highly  of 
the  carbonate  of  ammonia,  given  in  large  and  frequent  doses.  It 
appears  to  me  to  fulfil  various  indications,  in  these  cases,  while  it 
is  a  valuable  diffusible  stimulant,  and  affords  a  concentrated  ma¬ 
terial  for  assimilation  and  nutrition.  I  must  place  confidence  in 
,  opinions  lately  published  in  regard  to  its  influence  as  a  solvent  of 
the  plastic  materials  of  the  blood.  When  the  vitality  of  both  the 
solids  and  fluids  is  reduced  to  as  low  a  degree  as  they  usually  are 
in  typhoid  pneumonia,  the  blood,  after  remaining  for  days  in  an 
engorged  lung,  must  tend  to  coagulation.  The  fact  is,  in  many  of 
these  malignant  cases  there  is  scarcely  sufficient  vitality  to  prevent 
it.  It  is  under  these  circumstances  that  the  carb.  ammonia  is  of 
incalculable  value.  I  am  fully  satisfied  that  it  aids  the  circulation 
through  the  congested  pulmonic  capillaries  by  its  solvent  powers. 

“In  most  cases  where  the  system  possessed  sufficient  vital  power 
to  react  after  the  first  chill,  a  very  low  form  of  remittent  fever 
was  associated  with  the  pneumonia.  The  pulse  and  animal  heat 
declined  very  much  during  the  morning,  but  towards  evening  a 
febrile  exacerbation  generallv  occurred.  This  indication  led  to  a 
free  use  of  quinine  in  combination  with  the  other  remedies,  and  I 
thought  with  much  advantage. 


60 


REPORT  ON 


“In  none  of  our  typhoid  cases  was  depletion,  either  local  or  gene¬ 
ral,  resorted  to.  Blisters  were  used  in  the  latter  stages  of  the  dis¬ 
ease,  but  with  little  perceptible  effect.  Mercury,  generally  in  the 
form  of  blue  pill,  was  administered  from  the  first,  in  all  cases  with¬ 
out  an  exception,  for  the  purpose  of  removing  the  latent  pulmonic 
inflammation;  but  as  its  effects  were  slow,  the  system  of  the  pa¬ 
tient  had  to  be  sustained  by  the  powerful  stimulation  above  men¬ 
tioned,  until  the  recurrence  of  the  specific  effects  of  the  mercury. 

“Our  usual  formula  was  pil.  hydrarg.  gr.  iij  ;  sulph.  quiniae  gr. 
iij;  pulv.  Doveri  gr.  ij,  every  three  hours  until  the  mercurial  im¬ 
pression  occurred,  at  the  same  time  continuing  the  use  of  stimu¬ 
lants  and  nourishment.  In  many  cases  in  which  for  days  prostration 
was  so  excessive  as  to  prevent  febrile  reaction,  as  soon  as  the 
specific  impression  of  mercury  was  made,  febrile  reaction  with  a 
good  full  pulse  came  on.  Purgation  was  restrained  with  opiates, 
generally  in  the  form  of  Dover’s  powder,  or  tinct.  opii. 

“Dr.  Norwood’s  tinct.  of  verat.  virid.  was  resorted  to  in  some  of 
our  cases  of  active  acute  pneumonia.  In  such  cases  it  is  quite  equal 
to  its  reputation,  and  Dr.  Norwood  deserves,  I  think,  great  credit 
for  bringing  it  before  the  profession. 

“One  case  I  will  mention  of  double  pneumonia  in  which  the  pulse 
was  a  hundred  and  fifty,  but  small;  skin  very  hot,  acute  pain  in 
the  chest  on  both  sides,  and  great  difficulty  of  breathing.  The 
tinct.  of  veratrum  wa‘s  given  in  four  drop  closes  every  three  hours. 
In  twenty-four  hours  the  general  symptoms  had  so  far  subsided 
that  the  patient  considered  herself  well. 

“On  withdrawing  the  remedy,  the  same  symptoms,  but  in  a  modi¬ 
fied  form,  recurred  again,  and  were  a  second  and  last  time  subdued 
by  the  remedy.  For  the  pneumonia  of  very  young  infants,  the 
veratrum  in  very  minute  doses  was  resorted  to  with  the  happiest 
effects.  For  such  cases,  I  believe  it  one  of  the  safest  and  best 
remedies  in  our  possession. 

“This  constituted  our  entire  treatment  of  nearly  fifty  cases  of 
typhoid  pneumonia,  with  the  loss  of  only  one,  in  which  the  treat¬ 
ment  was  too  late.  After  apparent  recovery  in  some  cases,  the 
lung  remained  indurated  and  impervious  to  air  for  several  months. 
Iodide  of  potassium  in  large  doses  invariably  removed  the  condition. 

“A  not  inconsiderable  observation  of,  and  experience  in,  the 
management  of  typhoid  pneumonia,  induces  me  to  believe  that,, 
when  treated  as  energetically  by  stimulants  as  we  ordinarily 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


61 


treat  the  acute  form  by  depletion,  the  mortality  would  be  about 
equal  in  both  forms  of  disease.” 

Malarial  Pneumonia. — A  report  descriptive  of  a  form  of  pneu-  ' 
monia  thus  designated,  was  presented  to  the  North  Carolina  Medi¬ 
cal  Society  in  1857,  by  Dr.  Otis  Frederick'  Manson,  in  which  he 
claims  to  have  been  the  first  to  have  directed  the  attention  of  the 
profession  to  this  particular  type  of  the  disease. 

Dr.  Manson  remarks  that  “  the  existence  of  a  form  of  pneumonia 
having  some  undefined  connection  with  periodical  fever,  has  long 
been  known  and  noticed;  but  unfortunately  for  the  student  of  the 
present  day,  the  affection  has  not  attracted  the  attention  of  recent 
investigators,  and  is  only  cursorily  and  imperfectly  noticed  by  any 
of  the  modern  standard  authorities.  The  progress  of  pathology, 
the  advance  of  therapeutics,  and,  still  more,  the  change  of  that 
which  Sydenham  termed  the  Medical  Constitution  of  the  period, 
render  it  imperatively  necessary,  not  only  for  the  attainment  of 
correct  views  of  the  nature  of  disease  ;  but  even  for  the  recognition 
of  its  physiognomy,  that  its  descriptions  should  be  often  revised  if 
not  altogether  rewritten. 

“This  work,  to  a  great  extent,  has  been  accomplished  in  refer¬ 
ence  to  diseases  generally ;  but  as  this  affection  is  chiefly  seen  in 
regions,  if  not  inimical,  at  least  not  fertile  in  authorship,  the  task 
remains  (so  far  as  we  are  aware)  for  it  unperformed. 

“To  supply  this  deficiency  is  116 1  the  expectation  of  the  writer- 
but  he  trusts  that  he  is  enabled  to  afford  some  materials  from  his 
observation  which  mayr  be  of  some  aid  to  those  who  have  not  pos¬ 
sessed  his  clinical  advantages,  and  to  others  more  competent  who 
may  hereafter  direct  their  special  attention  to  the  subject. 

“In  my  opinion  the  phase  of  disease  whose  delineation  is  now 
attempted,  is  the  form  of  pneumonia  generally  seen  by  southern 
observers;  that  its  peculiarities  are  often  unrecognized,  being  often 
confounded  with  simple  typhoid  and  other  varieties  of  pulmonic 
lesion.  Not  only  this,  but  the  assertion  is  here  made,  that,  under 
proper  management,  this  disease,  although  of  decidedly  fatal  tend 
encies,  is  more  under  the  control  of  remedial  agents  than  any  of 
the  so  called  phlegmasiae. 

“If  these  declarations  are  true,  how  important  is  it  that  its  fea¬ 
tures  should  be  familiarly  known,  in  order  that  it  may  not  be  con¬ 
founded  with  diseases  chiefly  affecting  the  same  organ,  but  so  unlike 
in  character  and  nature.”  It  may  not  be  out  of  place  here  to  state, 
that  the  views  and  opinions  of  Dr.  Manson  have  not  been  received 
5 


62 


REPORT  ON- 


without  opposition.  They  have  been  especially  subjected  to  a 
minute  analysis  by  Dr.  W.  T.  Howard,  of  Warren  ton,  N.  C.,  who 
contends  that  the  disease  described  by  Dr.  Manson  as  malarial 
pneumonia,  does  not  differ  from  the  ordinary  types  of  that  disease 
with  a  malarial  impression  superadded,  and  that  in  this  form  it  has 
been  observed  and  described  by  numerous  writers.  Dr.  Manson 
continues : — 

“  General  course  and  progress. — Malarial  pneumonia  attacks  sud¬ 
denly,  being  almost  invariably  ushered  in  by  a  chill,  which  is  fre¬ 
quently  of  a  severe  intensity,  and  attended  with  rigors  of  variable 
duration.  In  very  grave  cases,  however,  the  system  is  prostrated 
almost  beyond  the  capability  to  react,  and  a  prolonged  cold  stage  is 
the  result.  Death,  however,  rarely  is  produced  from  this  cause  in 
the  early  stage,  but  fever  more  or  less  developed  soon  ensues.  In 
most  cases  the  patient  seems  to  hover  for  hours,  and  even  days,  be¬ 
tween  the  state  of  chill  and  febrile  excitement.  Pain  in  the  side  of  a 
pleuritic  character  is  generally  next  experienced,  it  being  absent 
in  very  few  instances.  To  the  reactive  fever  dyspnoea  and  cough 
soon  succeed.  In  some  cases,  however,  the  cough  is  tardy  in  its 
appearance,  or  is  so  slight  at  the  commencement,  as  to  elude  the 
notice  of  the  patient  and  physician.  Headache,  nausea,  and  vomit¬ 
ing,  are  very  frequent  and  prominent  symptoms,  and  frequently 
precede  the  cough  and  pain  ;  the  fluids  ejected  from  the  stomach 
being  usually  of  a  bilious  character.  The  cough  is  commonly  dry 
at  the  commencement,  or  attended  with  an  excretion  of  glairy  mucus; 
sooner  or  later,  however,  the  sputa  become  more  or  less  tinged  with 
blood,  forming  the  pathognomonic  ferruginous  expectoration,  the 
hues  of  which  are  as  numerous  as  the  proportions  in  which  blood 
and  mucus  may  be  mingled.  Thus  we  shall  see,  in  some  cases,  the 
latter  merely  tinged  with  blood ;  or,  as  more  frequently  happens,  a 
uniform  thin,  bloody,  frothy  fluid  is  only  seen,  possessing  but  little 
viscidity  or  tenacity,  whilst  in  some  instances  a  pure  and  copious 
haemoptysis  is  observed.  Later,  however,  the  expectoration  is  lia¬ 
ble  to  great  variations  in  color  and  hue  ;  thus  it  may  be  of  the 
various  shades  of  brown,  red,  and  yellow  commingled,  and  in  the 
advanced  stages  may  become  green,  or  almost  black.  The  febrile 
action  presents  decided  peculiarities,  being  usually  distinctly  par¬ 
oxysmal  and  remittent.  The  remissions  are,  however,  sometimes 
obscure,  and  an  active  fever  exists  during  day  and  night.  On 
watching  the  patient  closely,  however,  a  coolness  of  the  extreme 
parts  will  be  almost  invariably  observed,  generally  occurring  daily, 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


63 


and  during  the  morning  hours.  This  reduction  of  temperature 
may  be  confined  to  the  ends  of  the  nose,  toes,  and  fingers,  either 
separately  or  combined,  and  in  grave  and  rare  cases  may  extend 
over  the  entire  extremities,  or  even  the  whole  surface,  amounting 
to  a  state  of  collapse.  This  coolness  of  the  skin  is  not  generally 
felt  by  the  patient,  but  on  the  contrary,  when  it  is  present,  he  often 
complains  most  intensely  of  sensations  of  excessive  internal  heat, 
soliciting  the  introduction  of  cold  air  into  his  chamber;  and  as  we 
have  witnessed,  wishing  the  doors  and  windows  to  be  opened,  and 
the  fires  extinguished  wrhen  the  thermometer  stood  below  the  freez¬ 
ing  point  near  the  bed  of  the  sufferer.  A  marked  increase  of  fever 
follows  this  insensible  chill,  which  continues  to  increase  in  intensity, 
until  an  exacerbation  more  or  less  perfect  is  developed.  The  pulse, 
which  had  been  very  frequent  and  contracted  in  the  chill,  becomes 
expanded,  acquires  force,  and  sometimes,  though  rarely,  becomes 
full  or  tense.  The  term  compressible  applies  to  the  usual  condition 
of  the  pulse,  and  the  idea  entertained  on  its  careful  examination  is, 
that  the  heart  is  acting  with  only  a  seeming  force,  and  not  with 
real  vigor.  In  some  few  cases,  the  pulse  has  been  observed  to  be 
nearly  normal  or  morbidly  slow. 

“  The  respiration  in  the  chill  is  more  frequent  and  the  dyspnoea 
more  urgent  than  in  the  exacerbation.  The  breathing  is  usually 
irregular  on  account  of  the  pleuritic  pain,  but  when  this  is  absent, 
or  has  been  relieved,  the  respiration  is  often  but  slightly  embarrassed 
in  severe  cases  in  the  early  stage. 

“  The  disease  continuing  unchecked,  the  paroxysms  usually  be¬ 
come  less  marked,  the  respiration  becomes  more  continuously 
frequent  and  difficult,  the  acts  often  exceeding  sixty  per  minute; 
yet,  in  some  cases  of  a  grave  character,  the  breathing  is  scarcely 
accelerated  during  the  whole  course  of  the  disease.  A  new  symp¬ 
tom  now  sets  in.  The  patient,  who  before  may  have  been  entirely 
rational,  or  slightly  incoherent  in  sleep,  or  at  the  heights  of  the 
exacerbation,  suddenly  becomes  wildly  and  persistently  delirious. 

u  The  cough  now  often  ceases,  the  patient  often  breathing  appa¬ 
rently  better  than  when  in  a  more  hopeful  condition.  The  tongue 
becomes  brown  or  black  and  dry,  sordes  collect  on  the  teeth,  and 
the  skin  and  sclerotica  assume  a  jaundiced  hue.  The  delirium 
increases  in  intensity,  the  patient  growing  almost  uncontrollable, 
and  requiring  force  to  keep  him  in  bed;  and,  when  not  watched, 
rushing  out  of  the  house  when  nearly  pulseless  and  cold.  Quiet 


64 


REPORT  ON 


only  succeeds  to  this  raving  to  be  quickly  succeeded  by  the  curtain 
falling  on  the  last  scene  in  the  agonizing  drama. 

“  Such  are  the  usual  phenomena  presented  by  this  affection, 
when  left  to  the  unassisted  efforts  of  nature.  Death,  however, 
sometimes  occurs  evidently  from  the  embarrassed  functions  of  the 
lungs,  as  in  cases  of  the  idiopathic  disease,  produced  by  an  im¬ 
permeable  condition  of  its  parenchyma. 

“  The  termination  in  health  is  marked  by  the  gradual  diminution 
of  the  symptoms,  by  the  occurrence  of  diaphoresis,  by  a  copious 
secretion  of  urine,  and  yet  more  often,  by  the  discharge  of  greenish- 
black,  viscid,  inodorous  stools,  closely  resembling  tar  in  appearance. 
The  passages  by  degrees  become  of  a  lighter  color,  passing  through 
shades  of  green  and  yellow,  until  they  assume  the  natural  hue. 
The  expectoration  becomes  less  colored,  the  sputa  becoming  more 
homogeneous,  and  gradually  assuming  the  smooth  straw  colored 
appearance  characteristic  of  the  resolution  of  pulmonic  inflam¬ 
mations. 

“The  disease,  however,  sometimes  becomes  chronic,  with  copious 
purulent  expectoration  mingled  with  blood,  the  patient  passing 
into  hectic,  with  the  rational  symptoms  of  phthisis,  terminating  in 
death.  In  more  fortunate  cases,  the  disease,  after  many  weeks,  and 
even  months’  duration,  may  give  place  to  entire  restoration  to 
health. 

“  Physical  signs  and  physical  changes.  First  stage.  Engorgement  or 
active  congestion. — Advancing  no  claims  to  expertness  in  physical 
diagnosis,  I  feel  a  great  hesitation  in  expressing  my  opinion  in  re¬ 
gard  to  the  import  and  value  of  morbid  sounds  in  this  affection. 
I  feel  it  my  duty,  however,  to  say  that  the  crepitous  rlionchus 
regarded  by  Laennec  and  his  imitators,  as  the  earliest  pathogno¬ 
monic  sign  of  pneumonic  inflammation  in  general,  is  not  usually 
present  at  the  commencement,  nor,  indeed,  at  any  of  the  stages  of  this 
disease. 

“  That  it  is  sometimes  heard,  we  know,  but  that  it  is  so  commonly 
observed  as  to  possess  alone  any  very  important  signification  in 
estimating  the  extent,  precise  seat,  or  gravity  of  the  disease,  I  do 
not  with  my  present  experience  believe. 

“  Its  pathognomonic  value,  called  into  question,  at  the  time  of  its* 
promulgation,  by  Andral,  Chomel,  Cruveilhier,  and  others,  has  been 
more  recently  and  strenuously  contested  by  Stokes  and  the  celebrated 
professor  Skoda,  of  the  school  of  Vienna.  I  therefore  feel  more 
confidence  in  candidly  expressing  my  views. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


65 


“It  is  difficult,  after  perusing  the  works  of  Laennec,  Williams, 
Walsh,  Barth,  and  Roger,  and  others,  and  observing  the  positive 
declarations  made  by  them,  in  regard  to  the  existence  and  value  of 
this  sound,  to  withhold  a  belief  in  their  statements.  On  the  other 
hand,  it  is  equalty  impossible  to  consult  the  distinguished  authori¬ 
ties,  above  cited,  without  being  convinced  that  they  are  penned  by 
skilful  and  truthful  observers.  I  do  not  know  how  these  conflict¬ 
ing  views  can  be  reconciled,  save  by  the  supposition  that  their 
authors  were  observing  different  forms  of  pneumonic  lesion. 

“If  the  peculiar  variety  of  pneumonia  now  under  consideration, 
or,  if  this  phrase  is  objectionable,  if  the  condition  of  the  organism 
with  which  inflammation  of  the  substance  of  the  lungs  in  the 
present  disease  is  found  associated,  is  widely  different  from  that 
described  by  the  majority  of  authors,  then  it  is  reasonable  to 
suppose  that  some  diversity  in  the  physical  signs  should  be  ob¬ 
served. 

“  If  in  this  disease,  as  we  shall  contend,  the  pathological  condition 
of  the  lung  usually  partakes  more  of  the  character  of  congestion 
than  open  inflammatory  action,  then  the  absence  of  crepitation  may 
be  explained  without  impeaching  the  testimony  of  those  who  have 
sought  to  affix  it  to  the  first  stage  of  pneumonia  as  the  diagnostic 
sound.  The  presence  of  crepitating  rale  is  justly  and  reasonably 
ascribed  to  the  passage  of  air  through  the  viscid  pathognomonic 
secretion  in  the  air  cells  and  minute  bronchi;  that  secretion  being 
considered  the  result  of  inflammation. 

*  “Now,  although  this  fluid,  as  proven  by  its  expectoration,  is 
present  in  all  varieties  of  pneumonia,  yet  it  is  usually  more  fluid 
and  more  sanguineous  in  this  than  in  simple  pneumonia,  and  we 
should,  therefore,  rationally  conclude  that  the  passage  of  air  through 
fluids  of  varying  tenacity,  density,  and  composition,  would  produce 
sounds  of  varying  character.1  Again,  it  often  occurs  in  the  early 
stages  of  this  affection,  that  the  cough  is  unattended  with  expecto¬ 
ration  for  several  days ;  indeed,  we  have  seen  cases  of  the  most 
violent  character  terminating  in  death  by  apnoea,  with  expectoration 
scarcely  sufficient  in  quantity  to  betray  the  character  of  the  affec¬ 
tion  ;  the  cough  being  dry  throughout  and  the  dyspnoea  extreme. 

“  How  in  these  cases  we  should  be  prepared  to  learn  that  no 
crepitation  would  be  heard,  or  if  observed,  not  in  proportion  to  the 
extent  or  gravity  of  the  pulmonary  lesion.  Again,  in  describing 

1  Laennec  himself  only  cites  two  cases  of  this  form  of  pneumonia,  in  which  the 
glutinous  sputa  and  crepitous  rhonchus  were  observed.  [Forbes’  Translation,  219.] 


66 


REPORT  ON 


the  anatomical  characters  of  pneumonia,  Laennec1  admits,  that 
inflammation  of  the  bronchi  is  a  frequent  attendant  on  the  simple 
form,  its  lining  membrane  being  commonly  very  red,  occasionally 
swollen,  the  redness  sometimes  extending  over  the  whole  bronchi. 

“Now  if  this  be  true,  and  who  will  gainsay  it,  how  is  it  possible 
that  sonorous,  sibilous  and  mucous  rhoncbi,  should  not  be  often 
heard,  as  maintained  by  Skoda,2  and  if  present,  drowning,  accord¬ 
ing  to  Andral,3  the  less  audible  sound  of  crepitation  ?  But,  as  has 
been  premised,  as  the  anatomical  character  of  this  affection  is  doubt¬ 
less  an  intense  congestion  of  the  parenchyma,  associated,  perhaps, 
in  some  degree  with  inflammation,  it  is  probable  that  the  absence 
of  crepitation,  in  the  large  majority  of  cases,  may  be  thus  explained. 
In  the  first  stage  of  this  disease,  we  may  have,  therefore,  the 
crepitating  rale  or  mucous  rales,  in  varying  degrees,  accordingly 
as  the  character  of  the  case  may  partake  of  inflammation  or  active 
engorgement. 

“  In  many  cases,  however,  the  practitioner  will  fail  to  observe 
any  morbid  sound,  although  the  concurrent  symptoms  may  render 
the  diagnosis  positive.  In  these  instances  the  crepitating  rale  may 
sometimes  be  elicited  by  engaging  the  patient  to  cough  forcibly,  as 
advised  by  Barth  and  Boger.  Although  as  I  believe  crepitation 
is  neither  pathognomonic,  at  least  of  this  variety  of  pneumonia,  or 
confined  to  inflammatory  affections  of  the  parenchyma,  being  sim¬ 
ply  the  sound  produced  by  the  passage  of' air  through  a 'viscid 
fluid  in  minute  tubes  ;  yet,  when  present,  its  importance  should  not 
be  undervalued,  as  when  taken  in  connection  with  other  signs  and 
symptoms  it  affords  a  valuable  aid  to  diagnosis. 

“  There  are,  however,  as  has  been  already  indicated,  other  sounds 
observed  in  the  first  stage  of  this  disease.  Early  in  the  invasion, 
in  some  cases  on  the  first  day  of  its  existence,  there  is  a  copious 
sero-sanguineous  secretionor  exhalation  present,  obstructing  the  cur¬ 
rent  of  air  in  the  bronchi,  trachea,  and  larynx.  In  these  instances, 
therefore,  we  have  abundant  bronchial,  tracheal,  and  laryngeal 
rales,  which  may  often  be  heard  at  some  distance  from  the  patient. 
On  the  other  hand,  as  we  have  observed,  all  sounds  indicative  of 
disease  are  absent.  Dyspnoea,  pain,  cough,  peculiar  sputa,  and  every 
other  symptom  may  be  present,  yet  no  sound  save  the  vesicular 
murmur,  perhaps  louder  than  in  health,  is  heard,  the  chest  being  at 
the  same  time  clearly  resonant  on  percussion. 

1  Forbes’  Translation,  220.  2  Ibid.,  306.  3  Note  to  Laennec,  246. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


67 


“In  these  cases  the  pneumonia  is  either  central,  or  the  secretion 
in  the  air-cells  and  finer  branches  of  the  bronchi  may  not  be  pre¬ 
sent  in  quantity  sufficient  to  offer  any  obstacle  to  the  passage  of 
air.  Whatever  explanation,  however,  may  be  offered,  I  am  fully 
persuaded,  after  careful  exploration  of  the  chests  in  many  cases 
daily  and  hourly  made,  that  at  least  in  the  early  stage  of  this  form 
of  pneumonia  no  abnormal  sounds  can  be  observed. 

“  Second  stage.  Solidification ,  Hepatization. — These  terms  are 
synonymously  used  to  denote  that  condition  of  the  lung  in  pneu¬ 
monia,  in  which  it  is  no  longer  permeable  to  the  air,  but  doubtless 
too  often  indiscriminately  used.  In  this  affection,  as  we  have 
repeated  and  shall  endeavor  to  maintain,  the  state  of  the  lung  pa¬ 
renchyma  partakes  more  of  the  character  of  congestion  than  active 
inflammation.  There  can  be  but  little  doubt  but  that,  in  a  great 
proportion  of  cases,  some  degree  of  inflammation  exists,  as  proven 
by  the  presence  of  fixed  pain,  the  peculiar  sputa  and  other  symp¬ 
toms ;  but  as  we  have  premised,  the  expectoration  is  of  a  different 
character,  partaking  more  of  the  appearance  of  diluted  blood  or  of 
a  sero-sanguineous  nature. 

“When  therefore  perfect  dulness  on  percussion,  and  absence  of 
the  respiratory  sounds,  betoken  condensation  of  the  lung  in  this 
disease,  it  is  not  in  my  opinion  due  to  an  inflammatory  process 
with  lymph  effusion,  as  in  the  frank  form  of  pneumonia,  and  to 
which  the  term  hepatization  has  been  properly  applied.  We  shall 
endeavor  to  substantiate  these  views,  when  the  nature  of  this  affec¬ 
tion  is  considered. 

‘‘  Lungs,  says  Walshe,  which  the  naked  eye  would  judge  to  be  in 
the  same  condition,  in  regard  to  their  shares  of  air,  fluid,  and  semi¬ 
plastic  substance,  it  is  evident  acoustically  are  in  different  physical 
states;  specimens  of  parenchyma  apparently  identical  are,  in  re¬ 
ality,  widely  different.  In  estimating  the  conducting  power  of 
lungs,  there  can  be  but  little  doubt  that  varying  homogeneousness 
is  a  more  important  element  than  any  so  called  ‘solidification  in 
pneumonia.’ 

“  ‘  Dulness,’ says  Blakiston,1  ‘will  result  from  sanguineous  con¬ 
gestion  of  the  cellular  portion  of  the  lungs  in  contact  with  the 
walls  of  the  thorax,  whether  of  a  passive  character,  being  the  re¬ 
sult  of  obstruction  to  the  circulation,  or  of  an  active  character,  as 
in  the  early  stages  of  pneumonia.’2  Andral  considered  hepatiza- 


1  Pract.  Observat.  Dis.  Chest,  37. 


2  Patliol.  Anat.,  vol.  i.  511. 


68 


REPORT  ON 


tion  to  arise  from  congestion  of  blood,  and  not  from  lymph  effusion, 
and  in  this  opinion  Stokes  also  concurs.1  Blakiston  we  think  rea 
sonably  concludes,  and  cites  experiments  in  proof,  that  in  pneu¬ 
monia  there  are  two  forms  of  solidification,  one  of  which  is 
produced  by  congestion,  and  the  second  by  deposition  of  lymph.’ 

“  Percussion  signs  of  solidification. — ‘  The  thoracic  walls,’  says 
Skoda,  ‘beneath  which  the  hepatized  lung  lies,  yield  a  dull  percus¬ 
sion  sound,  and  their  resistance  is  increased,  provided  the  hepatized 
portion  of  the  lung  has  the  thickness  of  about  an  inch,  and  an 
extent  greater  than  that  of  a  pleximeter.  The  more  extensive-  the 
hepatization,  the  duller  is  the  sound,  and  the  greater  the  resistance. 
If  the  sound  is  completely  flat,  as  elicited  in  striking  the  thigh,  then 
the  lung  is  solidified  throughout  its  whole  thickness.’ 

“  Auscultatory  signs. — According  to  Laennec,  in  hepatization,  the 
crepitous  rhonchus  and  vesicular  murmur  are  absent  in  the  affected 
part,  and  this  is  frequently  the  only  proof  afforded  of  solidification 
having  occurred,  bronchophony  existing  in  certain  cases,  if  the 
inflammation  is  seated  near  the  roots  of  the  lungs,  or  in  the  su¬ 
perior  lobes,  where  the  bronchial  tubes  are  largest.  When  the  pneu¬ 
monia  is  central,  bronchophony  is  absent  or  obscure,  becoming 
more  manifest  if  the  inflammation  approaches  the  surface  of  the 
lungs;  this  being  easily  accounted  for,  he  observes,  as  a  hepatized 
lung  is  a  better  conductor  of  sound  than  a  healthy  one,  broncho¬ 
phony  being  nothing  more  than  the  resonance  of  the  voice  within 
the  bronchi  of  the  inflamed  part. 

“Bronchial  respiration  and  bronchial  cough,  according  to  the 
same  author,  always  accompany  bronchophony,  and  when  the  he¬ 
patization  is  near  the  surface  and  involves  within  it  bronchial  tubes 
of  considerable  size,  then  it  is  frequently  accompanied  by  a  sensa¬ 
tion  of  blowing  into  the  ear  (, souffle  dans  V oreille)  and  if  a  thin  por¬ 
tion  of  pulmonary  substance  not  yet  hepatized  intervenes  between 
the  ear  and  the  affected  bronchi,  the  sensation  denominated  the 
veiled  puff  ( souffle  voile)  is  produced. 

“  The  auscultatory  sounds  as  described  by  Skoda  more  nearly 
accord  with  my  limited  experience.  I  however  do  not  feel  com¬ 
petent  to  pronounce  on  the  correctness  of  his  theory  of  conso¬ 
nance.  He  says,  ‘  When  the  hepatized  portion  is  extensive  enough 
to  contain  within  it  at  least  one  of  the  larger  bronchial  tubes,  and 
if  the  tube  contains  air,  is  not  obstructed  and  communicates  with 


1  Dis.  Chest,  286. 


THE  EPIDEMICS  OF  N 0 RTH  CAROLINA. 


69 


the  trachea,  then  the  voice  of  the  patient  will  consonate  in  the 
bronchial  tube  and  be  heard  either  as  loud  or  weak  bronchophony 
over  those  parts  nearest  the  tube.’ 

“  The  respiratory  sounds  vary  according  to  the  nature  of  the 
rales,  in  the  larynx,  trachea,  or  bronchi,  through  which  the  air  must 
pass  before  it  enters  the  bronchial  tube  surrounded  by  the  hepa- 
tized  tissue.  The  respiratory  murmur  may  alone  be  heard,  or,  in 
addition  to  this,  hissing,  whistling,  and  sonorous  sounds,  either 
*  separately  or  combined.  If  the  hepatized  portion  of  the  lung  be 
not  large  enough  to  contain  one  of  the  larger  bronchial  tubes,  or 
if  it  be  large  enough,  but  the  tube  be  filled  with  fluid  or  solid 
matters,  or  if  the  communication  between  the  tube  and  the  trachea 
be  obstructed  by  mucus,  blood,  &c.,  then  neither  bronchophony  nor 
bronchial  breathing,  nor  high,  clear  rales  nor  hissing,  whistling,  or 
sonorous  sounds,  will  be  heard  over  the  hepatized  lung ;  the  patient’s 
voice  will  be  inaudible ,  or  recognizable  onlv  as  a  dull  muttering, 
and  the  respiratory  murmur  indistinct  or  absent. 

“  Whether  the  explanation  of  Skoda  is  correct  or  not,  I  cannot 
say,  but  certainly,  in  a  large  majority  of  my  cases,  neither  broncho¬ 
phony,  bronchial  breathing,  or  bronchial  cough  have  been  observed. 
I  am  inclined,  however,  to  attribute  their  absence  to  the  fact,  that 
in  this  variety  of  pneumonia,  the  impermeability  of  the  lung  being 
due  to  excessive  engorgement,  and  not  to  lymph  exudation,  it, 
therefore,  does  not  possess  the  requisite  density  to  make  it  a  good 
conductor  of  sound. 

“  Third  stage.  Purulent  infiltration. — This  is  a  very  rare  termi¬ 
nation  in  this  form  of  pneumonia.  When  present,  the  physical 
signs  do  hot  differ  from  those  of  solidification.  A  well  marked 
case  of  this  condition  came  under  my  care,  which  was  attended  with 
copious  purulent  expectoration  tinged  with  blood,  being  of  a  yel¬ 
lowish-pink  hue,  the  quantity  evacuated  being  at  least  two  pounds 
per  day  for  several  consecutive  days.  Laryngeal,  tracheal,  and 
bronchial  rales  were  distinctly  heard  at  a  distance  of  several  feet 
from  the  patient.  Percussion  yielded  a  dull  flat  sound  over  the 
whole  thorax,  below  the  fourth  rib,  on  each  side  beneath  which  no 
sound  of  the  voice,  cough,  or  respiration  could  be  heard.  Above 
this  line  percussion  yielded  a  clear  sound,  and  the  ear  discovered  a 
coarse  humid  rhonchus  with  large  bubbles,  evidently  due,  like  the 
sound  in  the  windpipe  above,  to  the  passage  of  air  through  the 
abundant  purulent  secretion. 

“  Signs  of  resolution. — When  this  occurs,  according  to  Laennec, 


70 


REPORT  ON 


in  the  first  stage,  the  crepitous  rhonchus  becomes  daily  less  per¬ 
ceptible,  and  gradually  yields  to  the  normal  respiratory  murmur. 
When  hepatization  has  taken  place,  its  resolution  is  announced  by 
the  return  of  the  crepitous  rhonchus  ( rale  crepitant  de  retour  rhon¬ 
chus,  rhonchus  crepitans  redux).  Skoda,  on  the  other  hand,  maintains, 
and  his  views  accord  with  my  own  observation,  that  the  period  of 
resolution  is  not  invariably  attended  with  the  appearance  of  the 
crepitating  rale,  but  in  most  cases  is  accompanied  with  a  great 
variety  of  rales,  or  by  whistling,  hissing,  and  sonorous  sounds. 

“In  some  rare  cases,  he  adds,  no  rales  whatever  appear  during 
resolution,  the  bronchial  breathing  being  at  first  indeterminate  and 
at  last  vesicular.  £  The  crepitating  rale,  or  a  rale  resembling  it,’  he 
adds,  is  heard  during  the  resolution  of  moderately  severe  cases  of 
pneumonia;  it  is  also  occasionally  observed  in  severe  cases  at  a 
more  advanced  period  of  the  resolution,  when  the  secretion  has 
become  scanty. 

“  In  the  greater  number  of  cases,  the  vesicular  breathing  does 
not  return  immediately  upon  the  resolution  of  the  disease ;  but  we 
generally  find,  after  all  the  functions  are  restored  to  their  healthy 
condition,  and  percussion  no  longer  yields  any  abnormal  sound, 
that  the  respiration  still  remains  indeterminate,  or  that  the  rales, 
or  hissing,  whistling,  and  sonorous  sounds  continue. 

“  Auscultation  yields  the  same  sound  when  the  resolution  is  in¬ 
complete.”  In  conclusion,  the  distinguished  author  sums  up:  “  It 
follows,  from  the  above,  that  the  presence  of  pneumonia  cannot  be 
determined  by  the  auscultatory  signs  alone ;  that  these  are  often 
very  indefinite,  and  that  bronchophony,  bronchial  breathing,  and 
other  sounds,  as  well  as  vesicular  breathing,  and  fine  equal  bub- 
ling  rales,  are  signs  which  of  themselves  do  not  enable  us  to  draw 
accurate  conclusions  as  to  the  condition  of  the  lung  parenchyma. 
In  forming  our  diagnosis,  we  must  also  take  into  consideration 
every  other  symptom  attainable  by  percussion,  and  by  other  means 
at  our  command. 

“  Diagnosis  between  Malarial  and  other  Forms  of  Pneumonia. — The 
varieties  of  pneumonia  with  which  this  affection  is  most  liable  to 
be  confounded,  are  simple  or  idiopathic  pneumonia  and  typhoid 
pneumonia.  I  shall,  therefore,  be  necessarily  compelled,  in  order 
to  institute  a  comparison  between  these  disorders,  to  glance  at  their 
predominant  characteristics.  I  shall  do  this  with  all  the  brevity 
which  the  importance  of  the  subject  and  my  faculty  of  condensation 
will  allow  me  to  use. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


71 


n  Simple  Pneumonia. — The  celebrated  Cullen,  whose  descriptions 
of  the  rational  symptoms  of  diseases  were  masterpieces  of  faithful 
delineation,  and  who  doubtless  drew  his  pictures  from  this  form  of 
pneumonia,  says:  ‘Pneumonic  inflammation,  however  various  in  its 
seat,  seems  to  me  to  be  always  known,  and  distinguished  by  the 
following  symptoms  :  pyrexia,  difficult  breathing,  cough  and  pain  in 
some  part  of  the  thorax ;  and  that,  for  the  most  part,  the  pulse  is 
frequent,  full,  strong,  hard,  and  quick.’ 

“  This  portrait  of  the  affection  continued  to  be  the  principal 
guide,  from  the  time  in  which  he  wrote  until  the  occurrence  of  the 
modern  discoveries  in  pathological  anatomy  and  physical  diagnosis. 
To  the  symptoms  laid  down  by  Cullen,  we  have,  therefore,  the  im¬ 
portant  aids  furnished  by  those  valuable  additions  to  our  science. 
In  drawing  a  comparison  thus  far  between  the  general  symptoms 
of  these  affections,  we  perceive  at  once  a  close  resemblance,  which 
would  amount  to  identity,  were  it  not  for  the  dissimilarity  in  the 
character  and  variations  of  the  pulse,  that  in  malarial  pneumonia 
being  frequent,  soft,  of  moderate  fulness,  compressible,  and  never 
or  rarely  very  full,  tense,  or  hard.  Nor  is  the  circulation  in  simple 
pneumonia  subject  to  the  same  diurnal  variations.  It  is  true,  that 
writers  aver  that  in  some  cases  of  the  latter  form,  the  fever  is  some¬ 
times  evidently  remittent;  but  granting  that  those  cases  did  not 
belong  to  the  malarial  disease  (though  we  strongly  suspect  the  con¬ 
trary),  still  I  think  that  a  marked  paroxysmal  character  is  seldom 
or  never  observed  in  the  simple  form. 

“The  regularly  recurring  cold  stage  is  another  guide  to  discrimi¬ 
nation,  seldom  absent  in  the  malarial  affection,  whilst  in  the  frank 
form,  the  skin  is  uniformly  of  an  elevated  temperature  in  the  great 
proportion  of  cases,  generally  being  hot  and  dry,  at  all  periods  of 
the  day  and  night,  whilst  in  the  exacerbation  of  the  former  disease, 
the  heat  is  more  moderate,  and  is  subject  to  a  daily  decline  in  the 
remission,  which  occurs  immediately  before  the  reappearance  of 
the  chill.  The  evidence  of  hepatic  and  gastric  disorders  has 
gained  for  the  malarial  form  the  epithet  of  ‘  bilious,’  and  although 
we  utterly  reject  that  view  of  its  pathology,  which  associates  either 
this  disease  or  any  form  of  malarial  disease  necessarily  with  hepatic 
lesion,  save  as  regards  the  occurrence  of  the  latter,  as  a  secondary 
affection  of  minor  importance,  yet  the  frequent  presence  of  nausea 
and  bilious  vomiting,  in  several  cases,  will  doubtless  afford  some 
aid  to  diagnosis  ;  those  hepatic  symptoms  dependent  on  sympathy 


72 


REPORT  ON 


of  contiguity,  when  the  inferior  lobe  of  the  right  lung  is  impli¬ 
cated,  in  pure  pneumonia,  being  of  exceptional  occurrence. 

“The  condition  of  the  bowels  in  this  disease  and  the  latter  is  also 
different.  In  the  malarial  form  the  intestinal  canal  seems  generally 
to  be  in  a  state  of  phlogosis  or  exalted  sensibility.  This  is  mani¬ 
fested  by  the  frequent  presence  of  diarrhoea ;  and  when  this  is  not 
evident,  by  the  hypercatharsis  often  induced  by  the  mildest  aperi¬ 
ents.  Later,  when  the  disease  succumbs,  convalescence  is  usually 
announced,  by  those  characteristic,  and  we  may  say  critical,  alvine 
evacuations  before  described. 

“The  expectoration  is  often  very  different  in  the  two  diseases. 
In  this  it  is  usually  less  viscid,  less  copious,  and  more  fluid,  par¬ 
taking  more  of  the  character  of  blood  mingled  with  serum;  in  fine,* 
presenting  more  of  the  character  of  a  defibrinized  blood  than  the 
usual  product  of  inflammatory  action. 

“The  presence  of  delirium  is  more  common  in  the  malarial  than 
in  the  simple  form.  In  the  former  it  is  usually  distinctly  intermit¬ 
tent  or  remittent  in  the  early  stages.  At  that  period  it  also  is 
usually  mild  in  its  character,  the  patient  seeming  to  be  in  a  state  be¬ 
tween  sleep  and  awake,  muttering  incoherent  and  rapidly  changing 
fancies,  but  when  fully  aroused  and  his  attention  directed,  replying 
in  a  rational  manner. 

“  The  delirium  is  evidently  of  a  neuralgic  character,  being  often 
attended  with  a  cool  skin  and  feeble  pulse,  with  no  other  symptom 
belonging  to  organic  cerebral  lesion,  and  like  the  hallucinations 
of  delirium  tremens,  to  which  it  bears  many  and  striking  resem¬ 
blances,  is  relieved  by  sleep  to  recur  again,  however,  in  the  febrile 
paroxysm.  Delirium,  however,  supervenes  under  other  circum¬ 
stances,  which  although  we  have  already  noticed,  constitute  such 
an  important  feature  as  will  excuse  a  repetition. 

“  Often,  without  any  previous  cerebral  symptom  whatsoever, 
after  the  pneumonic  symptoms  have  been  mitigated,  or  have  en¬ 
tirely  disappeared,  and  confident  hopes  are  entertained  of  the 
patient’s  recovery,  a  furious  delirium  suddenly  occurs.  I  cannot 
refrain  from  adding  this  striking  characteristic,  as  drawn  by  Cleg- 
horn:  ‘Besides  some  abatement  of  the  fever,  which  happened  every 
morning,  it  was  remarked  that  upon  the  third  day  or  beginning  of 
the  fourth,  there  was  frequently  a  great  remission,  sometimes  a 
total  cessation  of  every  violent  symptom,  so  that  the  sick  were 
thought  to  be  out  of  danger,  but  on  the  fourth  or  fifth,  a  delirium 
suddenly  came  on,  or  the  breathing  became  more  difficult  than 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  73 

ever,  and  one  or  both  of  these  symptoms  increasing  hourly,  the 
patient  expired  either  suffocated  or  raving  mad,  unless  nature  or 
art  assisting,  he  had  the  good  fortune  to  escape  by  some  critical 
evacuation.’  ”x 

It  has  happened  to  the  writer  to  have  seen  cases,  in  which  every 
rational  and  physical  sign  of  convalescence  had  made  its  appear¬ 
ance,  but  which  on  the  next  visit  were  found  to  be  in  the  same 
condition  as  when  first  attacked,  without  any  known  cause  which 
could  probably  be  assigned  for  the  change.  In  these  cases  it  will 
be  perceived  that  the  malady  was  strictly  intermittent,  and  the 
recurrence  of  the  symptoms  was  evidently  connected  with  the 
periodical  character  of  the  affection  and  the  liability  of  that  class 
of  diseases  to  relapse. 

"We  have  thus  briefly  pointed  out  the  variations  presented  by 
the  several  organs,  functions,  and  secretions,  to  aid  the  beginner  in 
discriminating  between  this  and  the  simple  form;  but  there  is 
another  phase  of  pneumonia,  with  which  it  is  also  too  often  con¬ 
founded,  and  which  of  late  years  is  seen  frequently  in  malarial 
regions,  and  from  which  it  is  equally  important  that  it  should  be 
distinguished,  viz.,  typhoid  pneumonia. 

“By  the  term  typhoid  pneumonia,  I  designate  that  species  of 
pulmonic  lesion  which  presents  itself  as  a  complication  of  the  form 
of  continued  fever,  for  many  years  widely  prevalent  in  the  old  and 
new  world,  and  by  general  acceptation  known  as  typhoid  fever. 
It  is  true  that  this  term  and  its  synonymes  have  often  been  applied 
-to  simple  and  malarial  pneumonia,  but  I  believe  on  erroneous 
grounds.  The  designation  typhoid,  asthenic  or  sthenic,  cannot  be 
applied  to  the  latter  disease,  as  the  exhibitions  of  vital  force  or 
reaction  are  too  variable  in  their  nature,  intensity,  and  duration, 
to  render  them  appropriate. 

“  Thus  we  have  seen,  in  some  cases  of  the  malarial  disease,  the 
vital  powers  were  almost  overwhelmed  at  its  onset,  continuing 
thus  for  days  together,  and  at  last  perhaps  followed  by  violent 
reaction ;  whilst  in  the  cases  generally,  there  were  such  diurnal 
changes  that  the  same  patient  might  have  been  regarded  in  an 
asthenic  or  sthenic  state  on  the  same  day,  accordingly  as  he  may 
have  been  seen  in  the  remission,  chill,  or  exacerbation.  It  is  true 
that  the  malarial  affection,  when  continuing,  finally  places  the 
patient  in  an  adynamic  state,  but  this  is  true  of  acute  diseases 


1  Diseases  of  Minorca. 


KEPOKT  ON 


74* 

generally,  and  must  be  regarded  as  a  sequent  and  not  as  an  origi¬ 
nal  condition. 

“  The  term  typhoid  cannot  be  properly  applied  to  any  form  of 
simple  inflammation.  In  my  opinion  pure  inflammation  of  the 
lungs,  occurring  in  a  previously  healthy  subject,  cannot  present 
typhoid  symptoms,  unless  it  is  associated  with  some  morbid  ele¬ 
ment,  which  impairs  the  resistant  powers  of  the  organism.  When, 
therefore,  such  a  patient  prominently  presents  the  symptoms  of 
pneumonia,  attended  with  deficient  vital  reaction,  the  inflammation 
of  the  lungs  is  a  secondary  or  collateral  affection,  and  not  the  pri¬ 
mary  or  essential  malady  under  which  he  is  laboring. 

“  Typhoid  pneumonia  may  be  presented  as  an  intercurrent 
affection,  but  often  the  inflammation  of  the  lungs  is  the  first  and 
most  conspicuous  symptom.  To  such  an  extent  and  so  marked  is 
the  expression  of  this  lesion,  that  the  practitioner  is  liable  to  re¬ 
gard  the  pulmonary  affection  as  the  sole  cause  of  the  illness  of  the 
patient,  and  not  perceiving  the  system  condition  with  which  it  is 
connected,  may  be  led  into  the  error  of  treating  it  as  such.  On 
minutely  inspecting  the  case,  however,  he  will  be  enabled  generally 
to  discern  its  true  character,  and  recognize,  under  the  veil  of  pneu¬ 
monia,  the  peculiar  form  of  fever  on  which  it  is  engrafted. 

“To  the  novice  we  offer  a  few  observations  as  guides  to  a  correct 
diagnosis.  Typhoid  pneumonia  usually  differs  from  the  forms 
before  mentioned :  1st.  In  its  mode  of  access.  It  is  usually  more 
gradual  in  its  approach ;  and  in  cases  in  which  the  pneumonic 
symptoms  announce  themselves  suddenly,  it  will  commonly  be 
found,  on  inquiry,  that  the  patient  has  been  indisposed  for  some 
time  before  their  appearance. 

“  2dly.  In  the  character  of  the  attendant  fever.  The  regularly 
recurring  paroxysms  of  malarial  pneumonia  are  absent,  the  firm 
full  pulse  of  the  simple  form  is  never  observed,  but,  on  the  other 
hand,  symptoms  of  great  depression  of  the  vital  powers  are  gene¬ 
rally  present. 

“In  short,  we  are  usually  enabled  to  discover  the  peculiarity  of 
the  case,  by  bearing  in  mind  that  the  patient  before  him  is  the 
subject  of  typhoid  fever  with  pneumonia  superadded. 

“Lastly.  In  diagnosing  the  various  forms  of  pneumonia,  we  should 
look  around  our  patient  and  endeavor  to  ascertain  the  sources  of  dis¬ 
ease  to  which  he  has  been  exposed,  whether  of  transitions  of  tempera¬ 
ture,  moisture,  contagion,  endemic,  or  epidemic  influence. 

“Although  the  rules  laid  down  are  generally  applicable,  we 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  ‘75 

should  ever  be  on  the  alert  for  fear  of  a  mistake.  It  is  desirable 
that  it  should  be  impressed  on  the  mind  of  the  beginner,  that  he 
will  often  be  compelled  to  diagnose  and  treat  many  cases  of  which 
his  knowledge  must  be  chiefly  drawn  from  the  character  of  the 
epidemic  present. 

“  Physical  signs  often  interpret  disease  imperfectly ;  symptoms 
are  merely  outward  expressions  of  an  internal  departure  from 
normal  vital  action ;  they  often  vary,  they  are  frequently  obscure, 
and  the  same  morbific  agent  has  so  many  different  modes  of  dis¬ 
playing  its  effects  on  the  organism,  that  many  instances  must 
present  themselves  to  the  observer  in  which  no  pathognomonic 
guides  will  be  perceived,  or  if  present,  undecidedly  and  imperfectly 
pronounced. 

“  Cause  and  Nature  of  Malarial  Pneumonia. — The  efficient  cause 
of  this  disease,  as  its  name  implies,  I  believe  to  be  malaria.  By 
this  term  I  desire  to  imply  the  identical  cause  of  that  class  of 
pyrexias  now  generally  known  as  periodical  fever. 

“  In  employing  this  description,  I  do  not  commit  myself  to,  or 
demand  a  belief  in  any  of  the  theories  concerning  its  origin,  but  as 
naught,  save  the  Great  First  Cause,  can  exist  without  a  creator,  so 
periodical  fever  cannot,  without  being  called  into  existence  by 
some  morbid  agency.  *  *  *  * 

“Nevertheless  there  are  some  axioms  which  may  be  regarded  as 
established  in  reference  to  this  source  of  disease,  which,  for  the 
elucidation  of  my  views,  it  is  necessary  to  bear  in  mind. 

“First.  The  primary  impression  of  malaria  is  depressing  in  its 
character. 

“Secondly.  Periodical  fever  may  owe  its  existence  to  an  ex¬ 
posure  to  its  cause  at  a  period  considerably  antecedent  to  its  deve¬ 
lopment. 

“Thirdly.  This  class  of  fevers,  though  chiefly  rife  in  the 
warmer,  may  occur  primarily  at  any  season  of  the  year. 

“Fourthly.  A  person  exposed  to  malaria  may  present  indubitable 
evidences  of  its  pernicious  influence,  without  any  regular  attack 
of  fever  having  occurred,  such  as  anorexia,  nausea,  malaise,  diar¬ 
rhoea,  neuralgia,  debility,  palpitation,  emaciation,  and  anasmia. 

“Fifthly.  Persons  constantly  exposed  to  malarial  influence  may 
retain  perfect  health. 

“  Sixthly.  In  persons  of  this  latter  class,  periodical  fever  is  often 
suddenly  developed  by  any  depressing  cause,  such  as  a  blow,  a  fall, 
a  shock,  and  by  the  incidental  occurrence  of  other  diseases. 


70 


REPORT  ON 


“  The  doctrine  that  this  form  of  pneumonia  owes  its  existence  to 
malarial  influence  has  long  been  entertained  and  acted  upon,  but? 
on  the  other  hand,  has  been  as  strenuously  contested,  both  in  regard 
to  its  correctness  and  legitimate  consequences.  The  subject  is  one 
of  great  interest  and  of  the  highest  importance,  involving  unques¬ 
tionably  the  lives  of  the  inhabitants  of  many  sections  of  our  own 
and  other  countries. 

“The  reader  who  has  had  frequent  opportunities  of  observing 
remittent  fever  at  the  bedside,  or  those  who  have  not,  who  have 
known  the  writer,  by  their  perusal  of  his  imperfect  descriptions  of 
that  disease,  cannot  fail  to  perceive  the  close  resemblance  between 
the  phenomena  presented  by  that  affection  and  the  disease  under 
consideration.  Indeed,  the  similitude  is  almost  perfect,  with  the 
addition  of  the  signs  and  symptoms  of  the  thoracic  lesion. 

“It  will  be  observed,  therefore,  that  the  evidences  of  organic  im¬ 
plication  are  by  no  means  confined  to  the  organs  of  respiration ; 
and  symptoms  of  gastro-intestinal  disorder  very  frequently  pre¬ 
ceded  the  lung  symptoms,  and  that  both  were  very  often  preceded 
by  febrile  excitement  for  hours  and  even  days.  AVe  have  seen  that 
the  patient  evidently  does  not  always  perish  from  the  pathological 
changes  wrought  in  the  lungs,  death  more  often  occurring  from  the 
supervention  of  fierce  delirium,  not  only  independent  of  the  lung 
affection,  but  subsequent  to  its  abatement  or  total  disappearance. 
These  facts  then  clearly  denote  the  connection  between  this  dis¬ 
ease  and  periodical  fever,  as  they  sufficiently  prove  that  its 
phenomena  are  not  merely  symptomatic  of  lesion  of  the  lungs. 

“By  some,  an  explanation  of  the  existence  of  this  disease  has 
been  given  by  attributing  it  to  the  combined  influence  of  malaria 
and  atmospheric  vicissitudes.  This  is  doubtless  often  true,  but  it 
does  not  offer  a  satisfactory  solution  of  the  fact,  that  many  are 
often  attacked  with  it,  who  have  not  been  exposed  in  any  appre¬ 
ciable  degree  to  those  changes.  Indeed,  this  affection  often  attacks 
a  number  of  persons  consecutively  in  the  same  household,  with 
sufficient  intervals  of  time  elapsing  between  the  occurrence  of  the 
cases  to  permit  all  conditions  of  temperature  and  humidity  to  ap¬ 
pear,  properly  belonging  to  the  season. 

“‘It  is  probable,’  says  Laennec,  ‘that  the  epidemic  peripneumony 
is  often  owing  to  deleterious  miasms,  which  have  entered  the 
system  by  means  of  the  cutaneous  or  pulmonary  absorbents,  since 
nothing  is  more  common  than  to  meet  with  cases  o!  this  disease, 
to  which  we  can  assign  no  occasional  cause.  How  many  persons 


THE  EPIDEMICS  OF  NORTH  CAROLINA.  77 

are  seized  with  it  in  their  very  chambers  and  in  spite  of  the  utmost 
care  taken  of  their  health.  It  is  impossible  that  any  observer  of 
ordinary  perception,  can  have  failed  to  have  been  often  impressed 
with  this  affection.  Exposure  to  atmospheric  alternations  does 
not,  therefore,  offer  a  complete  and  satisfactory  explanation  of  the 
general  occurrence  of  this  affection.7 

“  I  propose  with  some  diffidence  to  offer  a  few  thoughts  on  the 
subject.  It  is  a  fact  which  will  scarcely  be  questioned,  that  during 
the  prevalence  of  any  fever  in  seasons  of  low  temperature,  pulmo¬ 
nary  inflammation  is  prone  to  occur  as  a  complication.  In  scarla¬ 
tina,  rubeola,  typhoid  fever  and  other  febrile  affections,  it  is  very 
common.  There  are  some  causes,  therefore,  existing  and  belonging 
to  the  season,  which  either  excite  or  predispose  to  lesion  of  the 
lung  parenchyma. 

“  In  instituting  an  inquiry  into  the  operation  of  those  causes,  it 
will  be  necessary  to  bear  in  mind,  that  the  system  has  passed 
through  the  fervid  heat  of  summer,  the  balmy  temperature  of 
autumn,  by  transitions  more  or  less  variable  to  the  colder  season 
of  the  year.  Usually  the  outward  man  has  been  prepared  for  this 
change,  the  whole  surface  of  the  skin  having  been  protected  from 
the  effects  of  reduced  temperature  by  clothing  of  proper  quantity 
and  quality.  But  how  is  it  with  the  lungs,  the  only  remaining 
surface  besides  its  outlet,  which  is  exposed  to  the  direct  contact 
of  air  ?  What  has  been  done  to  protect  that  extensive,  delicate 
lining  of  the  air  tubes  and  air  cells ;  that  admirably  contrived 
membrane,  abundantly  supplied  with  bloodvessels  of  such  re¬ 
markable  construction  and  tenuity,  as  to  allow  the  permeation  of 
air  through  their  delicate  parietes,  and  yet  allow,  under  ordinary 
circumstances,  no  escape  of  their  contents? 

“  It  is  evident  that  this  great  annual  change  of  temperature 
cannot  take  place  without  some  important  physiological  revolution 
in  the  pulmonary  circulation ;  to  understand  the  nature  of  which, 
it  is  only  necessary  to  remember  the  usual  effects  of  reduced  tem¬ 
perature  upon  vascular  tissues  in  general.  The  first  impression  of 
cold  upon  the  lungs  must  necessarily  be  succeeded  by  contraction 
of  their  capillary  vessels.  Happily,  however,  our  organs  are  en¬ 
dowed  with  a  certain  degree  of  resistance  to  depressing  causes, 
under  the  operation  of  which  the  vessels  again  expand  and  allow 
the  free  transmission  of  their  contents.  In  short,  the  equilibrium 
of  health  is  established.  The  resisting  force  which  thus  averts  dis¬ 
ease,  or,  in  other  words,  the  nervous  force,  the  only  power  existing 
6 


78 


REPORT  ON 


in  the  system  of  which  we  are  cognizant,  must,  however,  be  con¬ 
tinued  and  maintained  in  order  that  no  embarrassment  to  the  cir¬ 
culation  may  ensue ;  consequently  throughout  the  colder  seasons, 
a  greater  amount  of  nerve  power  must  be  expended  in  the  lungs  to 
preserve  their  physiological  condition. 

“  Again,  the  effects  of  reduced  temperature  will  be  in  proportion, 
first,  to  its  intensity  and  duration,  and  secondly,  to  the  capability 
of  resistance  residing  in  the  system. 

“  If  we  suppose  that  the  system  is  contaminated  by  the  depress¬ 
ing  influence  of  malaria,  whether  enervated  by  open  attacks  of 
malarial  fever,  or  debilitated  by  its  latent  influence,  it  necessarily 
follows  that  such  a  person  must  be  in  a  favorable  condition  for  the 
development  of  pulmonary  engorgement,  from  the  fact  that  he  is 
subjected  to  a  temperature  requiring  a  healthy  nervous  force  to 
resist,  which  he  does  not  possess. 

“  There  is  plainly,  then,  a  degree  on  the  thermometric  scale, 
equivalent  to  disease  with  him,  yet  compatible  with  health  in 
others. 

“  Let  us  advance  one  step  further.  The  degree  of  cold  being 
present,  beyond  the  nervous  power  to  resist,  or  having  endured  so 
long  as  to  have  for  a  time  exhausted  its  resources,  let  us  look  again 
to  the  capillaries  of  the  lung.  If  the  vessels  contracted  by  the 
application  of  cold  do  not  possess  the  normal  resistant  vigor,  as  we 
have  assumed  as  an  axiom  in  the  malarial  diathesis,  the  same  or 
greater  effect  is  produced  than  by  a  more  intense  degree  of  cold 
acting  on  a  healthy  subject. 

“  Under  ordinary  circumstances,  however,  the  nervous  centres 
will  be  stimulated  to  react  (those  cases  attended  with  collapse  in  the 
commencement  being  the  exceptions),  the  reaction,  according  to  a 
law  of  the  organism,  being  in  proportion  to  the  previous  depression. 
‘An  increased  afflux  of  blood  to  the  part  consequently  ensues,  and 
as  the  action  of  cold  has  indirectly  produced  the  same  effect  as  that 
produced  by  a  direct  irritating  cause,  it  will  only  be  necessary  to 
follow  the  subsequent  steps  in  the  process  to  the  state  of  active 
congestion,  as  detailed  in  Kaltenbrunner’s  experiments.71 

“  But  there  is  yet  another  function,  which  has  also  to  undergo 
an  important  modification.  The  skin,  which  had  been  exalted  in 
the  warm  season  to  excessive  activity,  gradually  falls  into  a  state 
of  comparative  repose  as  the  bleaker  season  arrives.  This  evidently 


1  Watson’s  Practice,  art.  Active  Congestion,  p.  46. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


79 


occurs,  however  perfectly  it  may  have  been  protected.  This  sub¬ 
sidence  of  function  must  necessarily  be  followed  by  a  determina¬ 
tion  of  blood  to  the  internal  organs,  the  retrocession  being  greater 
and  more  easily  induced  in  malarial  subjects  for  reasons  before 
adduced. 

“  We  have  now  an  explanation  of  the  modes  by  which  cold  and 
malarial  influence  may  act  as  exciting  and  predisposing  causes  of 
this  affection ;  but  this  solution  does  not  wholly  apply  to  those 
cases  occurring  in  previously  healthy  subjects,  while  sedulously 
guarded  from  atmospheric  vicissitudes.  These  cases  are  evidently 
due  to  the  evolution  of  malaria,  the  affection  of  the  lungs  being 
produced  by  the  predisposing  tendencies  of  the  season. 

u  Objection  has  been  urged  on  many  grounds  to  this  view  of  its 
causation ;  the  principal  one  of  which  is,  that  pneumonia  prevails 
in  seasons  inimical  to  the  existence  of  this  mysterious  agent.  This 
is  plainly  an  error.  Primary  attacks  of  periodical  fever  not  un- 
frequently  occur  during  the  winter  and  spring  months,  especially 
in  the  latter,  which  is  also  the  season  in  which  this  form  of  pneu¬ 
monia  is  usually  prevalent.  The  opponents  of  the  views  I  have 
embraced  seem  to  ignore  this  established  fact,  as  old  as  the  ancient 
couplet : — 

1  An  ague  in  spring 
Is  fit  for  a  king.” 

“  They  have,  however,  been  compelled  to  yield  the  admission 
that  a  form  of  disease  similar  to  that  we  have  described  often  pre- 
wails  as  an  epidemic.  Now,  whether  it  be  regarded  merely  as  a 
complication,  a  compound,  or  as  a  hybrid  affection,  it  cannot  be 
disputed,  that  it  rages  in  these  seasons  of  the  year,  the  temperature 
of  which  they  assume  to  be  distinctive  of  malarial  influence.  The 
inconsistency  is  obvious. 

“The  occurrence  of  periodical  fever  not  only  in  the  spring,  but 
occasionally  in  the  winter  months,  being  easily  established,1 2  there 
are  conditions  necessary  to  notice,  closely  associated  with  its  nature 
and  phenomena,  which,  besides  the  tendencies  of  the  season,  assist 
in  producing  a  sanguineous  determination  to  the  lungs. 

“  When  discussing  the  subject  of  remittent  fever,  I  briefly  en¬ 
deavored  to  prove  its  nature,  from  the  character  of  the  symptoms 

1  Elliotson’s  Practice,  242. 

2  Under  tlie  name  of  adynamic  remittent,  I  have  described  a  form  of  remittent 
fever  often  seen  in  the  winter  season  in  my  region.  See  article  before  referred  to. 


80 


REPORT  ON 


existing  daring  life,  and  to  show  that  there  was  constant  tendency 
in  the  vital  current  to  retrocede  from  the  extremities  to  the  trunk, 
and  in  grave  cases  from  the  whole  surface  to  the  internal  organs. 
Of  the  cause  of  that  morbid  afflux,  I  then  avoided  discussion. 
I  do  so  now ;  but  in  my  opinion  it  is  produced  by  an  irritation  of 
the  nervous  centres  of  a  peculiar  character.  As  a  consequence  of 
this  irritation  and  congestion,  delirium,  difficult  locomotion,  dysp¬ 
noea  independent  of  pulmonary  engorgement,  with  varying  con¬ 
ditions  of  pulse,  and  abdominal  symptoms  were  observed  accord¬ 
ingly  as  different  portions  of  the  cerebro-spinal  axis  may  have  been 
involved. 

“To  sum  up  our  reflections  on  the  pathology  and  etiology  of 
this  form  of  pneumonia,  we  have  therefore  to  explain  its  production 
and  phenomena. 

“First.  The  predisposing  tendencies  of  low  temperatures  to  pro¬ 
duce  an  afflux  to  the  lungs,  by  direct  contact  with  their  interior 
surface. 

“Secondly.  The  same  cause  by  repression  of  the  cutaneous 
evacuation,  determining  to  the  whole  internal  organs. 

“Thirdly.  The  operation  of  malarial  influence,  which  not  only 
diminishes  the  vital  resistance  to  cold,  but  possesses  an  evident 
inherent  tendency  to  produce  internal  engorgement.1 

“A  glance  at  the  pathological  condition  of  the  lung  will  close  our 
observations  on  this  division  of  the  subject. 

“  I  have  repeatedly  stated  in  the  foregoing  pages,  my  impressions 
in  regard  to  the  condition  of  the  lung  parenchyma  in  this  affection, 
as  partaking  rather  of  the  nature  of  active  congestion  than  of  well 
developed  inflammation.  This  is  proven  in  my  opinion  by  the 
following  circumstances.  First.  The  sudden  occurrence  of  solidi¬ 
fication,  as  evinced  by  perfect  flatness  on  percussion  and  absence  of 
the  respiratory  murmur.  This  sometimes  takes  place  in  grave 
cases  in  a  few  hours  after  its  onset,  involving  more  than  half  of 

1  Broussais,  wlio  doubtless  saw  a  vast  number  of  cases  of  this  disease  whilst 
serving  in  the  French  armies,  and  who  lias  noticed  at  great  length  the  connection 
between  malarial  fever  and  pneumonia,  was  fully  impressed  with  similar  views. 
Cette  concentration  des  forces  a  l’interieur  ou  si’l  on  condamne  ces  expressions, 
cette  accumulation  violente  du  sang,  dans  les  capillaires  des  visceres,  qui  existe 
durant  la  x>eriod  de  froid,  des  intermittentes,  devient  surtout  funeste  au  pournon 
pendant  la  saison  froide.  Ilistoire  des  Plilegmasies  ou  Inflam.  Clironiques,  tome 
ii.  588.  See  also  works  of  Laennec  (op.  cit  ),  M.  Bailly,  Traite  des  Fievres  Int. 
Paris,  1825.  Cleghorn  (op.  cit.). 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


81 


the  entire  lungs,  accompanied  by  a  cold  skin,  flagging  pulse,  col¬ 
liquative  diarrhoea  ;  a  condition  of  system  totally  incompatible  with 
the  existence  of  the  inflammatory  process.  Secondly.  The  disap¬ 
pearance  of  the  physical  signs  is  too  rapid,  in  many  cases,  to 
suppose  that  inflammation  terminating  in  plastic  exudation  had 
produced  this  impermeable  condition  of  the  lungs. 

u  It  is  true,  as  we  have  stated,  that  there  are  some  evidences  of 
inflammation1  mingled  with  the  symptoms,  and,  as  active  congestion 
is  a  state  closely  allied  to  inflammation,  the  latter  may,  and  doubt¬ 
less  does  occur,  but  it  is  evident  that  inflammation  cannot  be  the 
general  condition,  as  it  is  too  expeditiously  removed,  in  many  cases 
of  several  days’  duration,  and  by  inadequate  means,  to  render  that 
view  admissible. 

“  Treatment.  In  the  chill. — In  this  stage,  it  is  evident  that  the  state 
of  internal  congestion  is  most  intense  ;  the  indications  are  therefore 
to  remove  or  lessen  this  condition.  As  in  ordinary  cases  the  vital 
powers  are  competent  to  produce  reaction,  the  employment  of  active 
measures  will  be  unnecessary;  but  when  the  cold  stage  is  serious 
and  protracted,  the  usual  means  adopted  in  remittent  fever  should 
be  called  into  requisition.  Warm  applications  are  to  be  assidu¬ 
ously  made  over  the  whole  length  of  the  spinal  column,  and  to  the 
extremities,  together  with  stimulating  frictions,  and  to  these  may 
be  added  warm  cataplasms  of  mustard,  or  of  capsicum  to  the  anterior 
and  lateral  surfaces  of  the  thorax.  If  these  means  should  be  un¬ 
successful  in  restoring  the  circulation  to  the  surface,  enemata  of  the 
-  sulphate  of  quinine  may  be  used.  Eight  or  ten  grains  of  the  salt 
dissolved  in  two  ounces  of  mucilaginous  fluid  may  be  thrown  into 
the  rectum  every  half  hour  or  more  often,  until  symptoms  of  reaction 
ensue.  If  diarrhoea  has  been  or  is  present,  the  following  enema 
will  be  more  efficacious: — 

Quinise  sulpli.  gr.  x  ; 

Morphia  sulpli.  gr.  ^  ; 

Acid,  sulpli.  dilut.  gtt.  x  ; 

Aquae  3 ij . — Misce. 

“  To  be  used  as  the  former,  but  at  longer  intervals. 

“  The  action  of  the  enemata  may  be  assisted  by  the  administra¬ 
tion  of  the  carbonate  of  ammonia  by  the  mouth,  or  infusions  of 
ginger  or  capsicum  whilst  warm  may  be  given.  In  extreme  cases 

1  In  Laennec’s  cases,  he  only  mentions  that  “  traces  of  inflammation  were  found 
after  death”  (op.  cit.,  249). 


82 


REPORT  ON 


it  will  be  necessary  to  resort  to  alcoholic  stimuli.  These,  however, 
should  be  used  with  caution,  and  their  effects  closely  observed. 

“Fortunately,  however,  it  is  rarely  that  much  difficulty  is  en¬ 
countered,  in  conducting  the  patient  through  the  cold  stage,  and 
medication  may  generally  be  postponed,  until  the  febrile  reaction 
is  developed. 

“  The  exacerbation. — The  indications  in  this  stage  are  to  calm  the 
action  of  the  heart,  to  remove  congestion  and  to  prevent  the  occur¬ 
rence  of  the  next  paroxysm.  If  the  pulse  is  hard,  full,  or  tense,  as 
it  is  in  rare  and  exceptional  cases,  or  if  the  patient  is  robust,  or  pre¬ 
viously  healthy  and  possessing  ordinary  vigor,  and  the  pain  or 
dyspnoea  is  very  intense,  and  the  character  of  the  pulse  or  other 
symptoms  does  not  decidedly  contraindicate  its  employment,  then  a 
moderate  quantity  of  blood  may  be  taken  from  the  arm. 

“  In  this  disease,  general  bloodletting  should  be  employed  with 
a  view  only  to  moderate  and  not  with  an  expectation  to  cut  short  the 
disease ;  nor  should  it  be  employed  except  in  the  instances  referred 
to.  In  cases  where  this  is  not  followed  by  marked  relief  and  in 
those  in  which  venesection  is  inadmissible,  the  local  abstraction  of 
blood  by  cups  or  leeches  should  be  resorted  to,  and  may  be  used 
as  freely  as  considerations  of  safety  will  permit.  The  time  at  which 
bleeding1  by  any  mode  should  be  practised  is  that  period  when  the 
exacerbation  has  reached  its  acme,  which  is  almost  invariably  in 
the  afternoon  or  evening. 

“The  administration  of  medicine  is  generally  postponed  until 
nine  or  ten  o’clock  P.  M.,  at  which  time  a  full  dose  of  calomel 
(fifteen  or  twenty  grains)  is  administered.  If  diarrhoea  or  a  tend¬ 
ency  thereto  is  present,  eight  or  ten  grains  of  Dover’s  powder  are 
generally  combined  with  the  mercurial.  Two  or  three  hours  there¬ 
after,  this  is  followed  by  a  full  dose  of  quinine  (fifteen  or  twenty 
grains),  in  pills  or  diffused  in  a  wineglassful  of  cold  water.  Three 
or  four  hours  are  now  allowed  to  elapse;  we  now  usually  repeat  the 
quinine  in  doses  of  five  to  ten  grains,  in  proportion  as  the  pulse 

1  In  the  remittent  fevers  denominated  pernicious  peripneumonic,  says  Laennec, 
it  may  no  doubt  sometimes  be  necessary  to  bleed  during  a  paroxysm,  in  order  to 
prevent  suffocation,  but  the  utmost  caution  is  necessary  not  to  destroy  unneces¬ 
sarily  the  strength  of  the  patien.  We  must  ever  keep  in  mind  that  bloodletting 
cannot  cure  a  disease  which  will  certainly  return  after  a  few  hours  with  fresh  vio¬ 
lence,  and  of  which  experience  has  long  since  demonstrated  bark  to  be  the  only 
remedy.  Op.  cit. ,  293. 


THE  EPIDEMICS  OF  NORTH  CAROLINA. 


83 


may  have  been  reduced,  until  thirty-five  to  forty  grains  have  been 
administered  and  the  patient  is  then  left  at  rest. 

“  According  to  my  experience,  the  chill  cannot  recur  whilst  the 
patient  is  under  the  influence  of  the  above  quantity  of  the  alkaloid ; 
the  fever  may  however  continue,  but  usually  in  a  very  moderate 
degree.  Should  this  be  the  case,  the  local  bleeding  is  repeated  in 
the  evening  exacerbation,  and  calomel  in  small  doses  of  one  or  two 
grains,  with  a  half  to  one  grain  of  ipecac,  or  two  grains  of  Dover’s 
powder,  is  given  every  one  or  two  hours. 

“  After  midnight,  the  quinine  is  repeated  in  the  same  manner, 
or  in  lesser  quantity  (in  direct  proportion  to  the  degree  of  fever 
present),  until  the  period  of  chill  has  passed,  when  all  medicine  is 
again  suspended.  It  is  rare,  indeed,  that  cases  thus  treated  in  the 
early  stages  do  not  exhibit  the  most  flattering  amendments,  on  the 
day  succeeding  the  first  night  on  which  the  plan  is  adopted  ;  and 
still  more  rare  that  every  dangerous  symptom  has  not  disappeared 
on  the  succeeding  day. 

“  Should  the  pneumonic  symptoms,  however,  persist,  the  mercu¬ 
rial  should  be  continued  until  its  constitutional  effects  are  produced. 
In  some  cases  in  which  the  arterial  action  is  not  disposed  to  yield, 
and  the  dyspnoea  continues,  I  have  ventured  on  the  use  of  tartar 
emetic  in  small  doses,  in  union  with  quinine.  I  am  indebted  to 
Dr.  Blakiston  for  a  knowledge  of  the  value  of  this  combination. 
The  antimonial  should  however  be  carefully  used ;  and  it  is  better 
to  commence  with  a  minimum  dose  of  one-tenth  or  one-twelfth  of 
*  a  grain,  to  be  gradually  increased  as  it  may  be  borne.  I  think  it 
proper  to  say  too  that  the  gastric  irritation  and  tendency  to  diarrhoea, 
so  often  present  in  this  disease,  contraindicate  the  employment  of 
tartar  emetic  generally. 

“  Whether  alone  or  in  combination  the  quinine  should,  however, 
be  continued  for  several  days  after  the  active  symptoms  have  dis¬ 
appeared.  Blisters  may  be  employed  at  almost  any  stage  of  the 
affection,  but  under  this  mode  of  treatment,  may  often  be  altogether 
dispensed  with.  Of  course  their  use  is  preferable  after  the  arterial 
action  is  moderated.” 

I  have  thus  endeavored  to  present  a  sketch  of  the  principal  epi¬ 
demic  diseases  which  have  recently  prevailed  in  the  State  of  North 
Carolina.  I  am  profoundly  sensible  of  its  incompleteness  and  its 
imperfections ;  for  notwithstanding  every  effort  on  my  part,  I  have 


84  REPORT  ON  THE  EPIDEMICS  OF  NORTH  CAROLINA. 


been  unable  to  secure  that  extent  of  co-operation  among  the  phy¬ 
sicians  of  the  State,  without  which  anything  approaching  a  complete 
picture  of  its  prevalent  diseases,  is  altogether  impracticable  ;  and  it 
is  now  submitted  only  in  obedience  to  the  sense  of  obligation  im¬ 
posed  upon  me  by  the  appointment  of  the  Association,  requiring 
me  at  least  to  make  an  effort  to  respond  to  their  wishes. 


